Laserfiche WebLink
, ILL�NOIS FUNDS ELECTROrTIC PPi1'MENT CLEARING ACCOUNT APPLICATION T H E 1 L L I N O I 9 F U N D S <br /> FAX YA: STATE TREASURER JUDY BAAR TOPINKA Md1I t0: STATE TREASURER JUDY BAAR TOPiNKA _ <br /> THE ILLINOIS FUNDS THE ILLIN0IS FUNOS ,PAY� <br /> (217)524-1269 3OO WEST JEFPERSON STREET <br /> SPRINGPIELD�ILLINOIS 62702 <br /> Date 6/2 9/0 S Application to partic:ipate in The Illinois Funds IIectranic Payment Program �ti'D°����'m <br /> � New Account Application ❑ Advanced Service(Files transfer) ❑ Change of information <br /> The Government described herein seeks to parlicipate in the Electronic Payment Services Program within The IIlinois Funds Money Market <br /> Fund,pursuant to Section 17 of the State Treasurer Act(15 ILCS 505/1�which authorizes the State Treasurer to establish a Fublic <br /> Treasurers'Inveshnent Pool. <br /> For Office Use Only: Account# Type Code: <br /> Describe your pubIic agency: <br /> City of Decatur 37-6001308 <br /> (Name of Agmcq) (FIIN Number/TIN Number) <br /> E-Pay Qearing- <br /> UtilitY, Invoice, Misc. Patty Hansen <br /> (Subtifle of Account) (Contact Person and Titie) <br /> One Gary K. Anderson Plaza, Decatur Macon 62523-1196 <br /> (Street Address) (City) (Counry) (Zip Code) <br /> 217-424-2705 217-424-2717 plhansen@decaturnet.org <br /> (Telephone Number) (FAX Number) (Contact Email Address-Email notificatian Yes/No} <br /> www.ci.decatur.il.us � <br /> (Web Address-Piease check box if E-Pay is linking from your home page) <br /> Type of service requested: �Credit Cards �FrChecks �Sliding Scale � Absorbing Fees ❑ Flat Fee �Checks Only Flat$2.40 <br /> ❑ IVR-Speech Recognition <br /> � InterneF <br /> � In Office-Over-the-Counter Terminal � Debit Cazds � Visa-MC �Amex � Discover <br /> For Office Use Only: ❑Global �ACH Direct ❑ Discover Card Only ❑E-Checks <br /> What is your gross revenue on an annual basis for payment type? Average Ticket$ <br /> ❑ Check here for fax notification of ACH deposifs to your Iliinois Funds account <br /> Withdrawal Options: <br /> By Check_ By Wire Transfer� By ACH Transfer�. <br /> (standard business checks) <br /> Transfer Instrvctions:(If more than one transfer path is needed,please submit a sepazate instruction sheet) <br /> See attached listing <br /> {Bank Name) (Further Credit to Your Account#) <br /> (ABA/Route#) (Cantact Name/Phone at Receiving Bank) <br /> Authorizations to sign checks or e�cecute Transfers:{If more than four,submit a separate sheet.) <br /> c <br /> Printed Name(s) Authorized Signature(s) Sign Checks Execute Transfers <br /> Rnn F. NPi�fPlrl �'---�- _ X $ <br /> Patricia L. Hansen ' " ; X � X <br /> Shawn Michelle Woods �� X X <br /> Intemst income will be posted to yonr acconnE(s)on the last bnsiness day of the month. . <br /> Particlpant accepts the terms and conditions of the administration of The IIIinois Funds as outlined by the State Treasurer with the understanding that <br /> there will be no changes to this agreement and the informatian contained herein without prior written notice.The Iliinois State Treasurer's office makes <br /> no representation as to the information loaded onto web server for the advanced service option at any given time. It is the responsibility of the participant <br /> to verify the accuracy of information pmvided on web site in comparison to data files transferredluploade� <br /> The undersigned hereby certifies that he/she is authorized to open an account(s)in The IIlinois Funds E-Pay Program and further certifies that said authority <br />� is statutory,or approved by the governing body of the above described Govemment. <br /> "�-- �- Citv Treasurer <br /> Signature: "` Position/Tifle: <br />