Special Purpose

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Type of Business
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School District Information

School District Name
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School District Address
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City
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State
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Zip
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Superintendents Name
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Superintendents Email
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Phone
Required! Must be a valid phone number i.e.: 123-456-7890

Fax
Required! Must be a valid fax number i.e.: 123-456-7890

Losses

Has the District ever made claim against a surety or fidelity bond?
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If yes, please give a description of the situation and the amount of any payment.
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Investments

Does the District have an investment counselor?
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If yes, who?
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Does the District invest in a liquid assets fund?
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If yes, which fund?
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District Treasurer

Treasurer's Name (First, Middle, Last)
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Home Address (Street, City, Zip)
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Home Phone
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Business Phone
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What other positions does the treasurer hold within the district?:
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Has this person ever been charged with any kind of criminal offense?
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If yes, please describe.
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Request

Request Type
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Continue Existing Bond #
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Anniversary Date
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Effective Date
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Date of Last Audit
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Was audit free from criticism?
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Amend Existing Bond #
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Date of Change
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Change Bond Amount From
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Change District Treasurer From
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Change Bond Amount To
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Change District Treasurer To
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Other Change
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Special Purpose Borrowing

Date of School Board Approval
Required

Purpose of Special Borrowing
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Total Amount Borrowed
Valid characters: 0123456789 , $

Amount Used to Date
Valid characters: 0123456789 , $

Remaining Amount
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*Bond Amount Requested
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The amount of the bond shall be 25% of the total of all bonds, notes, mortgages, moneys and effects of which the Treasurer is to have custody, adjustable only by the Regional Superintendent of Schools or the School Board of the District.

*All Special Purpose Borrowings Treasurer’s Bonds are subject to a minimum premium.

CERTIFICATION and SIGNATURE

The undersigned certifies that the information is true, correct and complete to the best of his/her knowledge.

Email
Please specify your email address.

Acceptance

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Name of Applicant
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