Treasurer's Bond Special Purpose Application

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Type of Business

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School District Information

School District Name

Required

School District Address

Required

City

Required

State

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Zip

Required

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?

YesNo Required

If yes, please give a description of the situation and the amount of any payment.

Required

Investments

Does the District have an investment counselor?

YesNo Invalid Input

If yes, who?

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Does the District invest in a liquid assets fund?

YesNo Invalid Input

If yes, which fund?

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District Treasurer

Treasurer's Name (First, Middle, Last)

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Home Address (Street, PO Box, Apt.)

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City

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Zip

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Home Phone

Required

Business Phone

Required

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?

YesNo Invalid Input

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?

YesNo Invalid Input

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

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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.

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Please specify your email address.

Acceptance

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I understand that checking this box constitutes a legal signature
confirming that I acknowledge and agree to the above Terms of Acceptance.

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Name of Applicant

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Security Code ◄

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Special Purpose

School District Information

Losses

Investments

District Treasurer

Request

Special Purpose Borrowing

CERTIFICATION and SIGNATURE

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