Account Registration Form - Office Of The Treasurer Of Indiana Page 3

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Account Registration Form
Key Contact
☐
☐
Mr.
Ms.
Print First and Last Name
Title
Signature (*required if Authorized Signer)
Phone
Email
Fax
Permissions (must check one)
Email Notifications
Online Account
☐
☐
☐
Authorized Signer to Move Funds*
Monthly Statements
Online User Access
☐
☐
Read Only Access
Transaction Confirmations
Additional Contacts
☐
☐
Mr.
Ms.
Print First and Last Name
Title
Signature (*required if Authorized Signer)
Phone
Email
Fax
Permissions (must check one)
Email Notifications
Online Account
☐
☐
☐
Authorized Signer to Move Funds*
Monthly Statements
Online User Access
☐
☐
Read Only Access
Transaction Confirmations
☐
☐
Mr.
Ms.
Print First and Last Name
Title
Signature (*required if Authorized Signer)
Phone
Email
Fax
Permissions (must check one)
Email Notifications
Online Account
☐
☐
☐
Authorized Signer to Move Funds*
Monthly Statements
Online User Access
☐
☐
Read Only Access
Transaction Confirmations
Note: All completed forms can be sent by email to clientservices@trustindiana.in.gov or by fax to 888-860-0963.
T 888-860-6242
clientservices@trustindiana.in.gov
F 888-860-0963

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