Request for New Clearing Account

State of Florida
Department of Financial Services
Division of Treasury
Bureau of Funds Management

Agency Name:
Mailing Address:
Contact Name:
Telephone Number:
Account Name:
Briefly explain the purpose of the fund: (including statutory reference)
Estimated annual dollar amount to be cleared:
Estimated annual number of items cleared:
List the name and physical location of the recommended qualified public depository:
Itemize quoted service charges for the depository:
Has the recommended qualified public depository agreed to the collateral and funds forwarding requirements of the State Treasury?
Are funds deposited into this account to be distributed to other accounts outside the State Treasury?
If yes, list the accounts and estimated amount to be transferred annually:
Clearing Fund?:
Revolving Fund?:
Recommended Schedule to Remit Funds to: Treasury (See Rule 69C-1, F.A.C.)

Division of Treasury
Bureau of Funds Management
Cash Management Section
200 East Gaines Street
Tallahassee, FL 32399-0344
Fax (850) 413-2724