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Dated this day of 20. Signature of Notary SEAL OR STAMP Typed or printed name of Notary Notary Public in and for the State of Wash. Bank Name Branch Location Bank Routing Number Account Number Persons authorized to make deposits and withdrawals for the entity listed above. Please mail this form to the address listed below OFFICE OF THE STATE TREASURER Date Received / / Fund Number PO BOX 40200 for LGIP use only OLYMPIA WA 98504-0200 FAX 360 902-9044 State of Washington County of SS. Signed or...

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