HomeMy WebLinkAboutSouth Central Banking Agreeementbusiness Account Application
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We lls Fa Bank M inne s o ta, Na
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officer maitre
COID I Da to
Erar7 h number I cost center
_ 3 0 ...... -- 2001 1
Officer aumber I Phone nwnber
S cott O 21783 73'921
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coo unt number Opening deposit
PF Choice IV C omm. I n - Pub l i 6 71
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Business name and address ,
City of o ak P ark H eights 1 - 57th St. N orth
O P ark Hei ghts, Mn 55082
Business telephone number Business Fax number TIN O rgani2arion type
65143944 6514390574 410941681 Go ver= ent Agen or U nit
Mo. /Yr. Bus{�ress started 'Arwkfal sales ftrnber of employees
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Entity ldenrifioation I)y .4ss[ }tired name verification by Isusiness located in the geographical area of bank? If no, stare reason for selectir?g beak,
Address verification by I Business type: filar }ufacruring, Service, retail, Wholesale, Agri ultcire I Description of prods }or or service solo'
Primary trade area
!Mayor suppliersIcu
lrrterrmarional transacti if yes, list type of transactions
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Identification Typ�;l1Vumber l�ecl� reporting status Previous batik reference
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Certification: girder penalties o f perjury, I certify that. R...�.4..... ..
I. Th number sho on this form is m y correct Taxpayer Iden tification Number, an
2 . UNLESS I IAA VE CHECKED ONE OF THE BOXES BE LOW, I am not subject to backup withholding either because I have not been
notified by t he Internal Revenue S ervice IRSJ that l air subject to backup withholding as a result of a failure to r a ll interest or
dividends, or the IRS has notified rite that I am no longer sub 'eet to backup withholding (does not apply to real estate transactions,
mortgage interest paid, the acquisition or abandonment of secured property, contributions to an Individual Re firem ent Art ngement
(IRA), and payments other than interest and dividends.)
D I am subject to backup withholding D l am exempt from backup withholding
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By . .
signing this application, I acknowledge that 1 have received a copy of the terms and conditions governing this account and agree to be bound by
them. Also, for non -Bark products, l v e have received a prospectus and understand that the products live am purchasing area not deposits or outer'
obfi a ions o the Bank, are trot issued, endorsed car guaranteed bar the Bank, and are not insured by a Agency or Ins tr rnantality of the Unite d States
Suc h as the Federal D eposit Insurance Corpora tiore FDIC" J, and involve invesrment risk, including possible loss of principal. I also C 0 rtify tha t the
information contained In my application is correct and/ agree to be bound b the terms of agreements for any additional services requested with this
ap lication, includingF those contained on the back page of this application. In the event of airy dispute arisingr under this Agreement, l a re to be
bound by the term s of the dispute resolution program, includingr arbitration as more Billy described in the Business A coo unt Fee and In orrrration
Schedule. ! understand that, under this program, at rrry request or the re quest of the Bank, disputes must be resorted by air arbitra #ion proceeding
before a neutral arbitrator. if arbitration is requested, I do not have the fight to a jury or court trial to resolve tine dispute.
!Name of authorized signor � ?nd brie Authorized signaarrr;
Ju Hol
(f inance)
W 14PIS (
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Oo you want your statements mailer! to an address othor than the address listed ors the first page? t Do you wart duplicate statement c opies� ��---'��.�",`: "':� �% µ :Vi; ='
❑ Yos Io Y es � fo
Mail to:
kf hat is the rrrailing address if different than the address s c -scifi -�" "-�" "`:-�.� ::
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Pleas& indicate which sere {ices you would like to help your business save time or money.
v� ells Fargo Member hi�p ankin ❑ dells 'ax Service ❑ Business xpre s
] ells argro usines G atov a Servic a roll Services
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y signing this applic t }on, l cknowle ige that I have received a copy o the terms and conditions goveming this account rid agree
to be bound b them.
l inne of : If the bank is located in I linnesota signing this ep� licetion, I declare that l have Trot had a checking or similar account
closed without my consent �rithin I months and I have Trot been convicted of a crime involving check or similar item ithin
months prior t airy becoming a signer o this account.
k�ellsTax: If I have selected to receive Well Tax services by signing this document I also certify that the in ormation contained in
m�y application is to the best of my knowledge correct, that I gill receive and read e copy f the greerrment 'o per orm utomated
Services Wells "ax , the " greement "), and that I ag ree to be bound by the terms of the � greemen t.
Business Express: I I have selected to receive Business x ress services, b signing this ocument I also certify that the in ormation
contained in m application is to the best of my knowlec ge cor'r'ect, that l iH receive and read a copy of the Business Express
Services gFreement, "the Agreement "), and that I agree to be bound by the terms of the greement.
li�lr " nnes to - Check Reporting Agency - Information on Individu is (For e Sole Proprietor, all authori ed signers of an unincorpor ted
association, are any partner of Partnership of or fearer partners who will have signing authority.)
I arr�e
Judy l
TIN
?ate of Birth
h�:ck Reporting Agency Infotmation
!Value
TIN
Data of Birth
Cheek Reporting A env Information _ .�._ ���
Name
7'111
Date of birth
Check Reporting Agency Information
side ,2 page I
South Central Service Cooperative insurance Pooling
WELLS FARGO BANK MINNESOTA, NATIONAL ASSOCIATION
Automated Clearinghouse (ACH) Authorization Agreement
MEMBER: C ity o oak Park Heights
FEDERAL ID CVO: 41-094168
Wells Fargo Bank Minnesota, National Association, is hereby authorized to initiate debit entries to the depository
(hereinafter called DEPOSITORY) and account named below, and to debt the same to such account.
DEPOSITORY NAME. Central Bank BLANCH: Stillwater
ADDRESS: 2270 F r o n tage Rd. W. CITY /STATE /ZIP: Stillwater, MN 55082
ox
TRANSIT/ABA Igo: 091905114 ACCOUNT No: 210419
This authority is to remain in full force and effect until WELLS 1=A GO BANK and DEPOSITORY Y h ire received
mitten notification from me or any of us of its termination in such time and in such manner as to afford WELLS
FARGO BANK and DEPOSITORY a reasonable opportunity to act on it. Wells Fargo B ank may assign this
Agreement to any successor by merger, consolidation or corporate reorganization.
UT o 1 ING SIGNATURES: The name (s) and signature( b must match th on the signature
card a t yo designated DEPOSITORY as identified above.
Judy L. Holst Thomas M. Melen
nP ted Authorized Name) (Printed uth ri e l Name) (Printed Authorized Dame)
Y i
/ 6� at L #) (si gnature) (signature)
7/6/01 7/6/01
( Date signed) (Date Signed) (Date signe
Wells Far Bank Account Number: 0671890887
"it understood that this account may be charged to satisfy all financial obligations for insurance pooling.
Earned interest accrues to account owner *„
Wells Fargo Bank contact: Jesse Christianson (507) 387 -9252 FAX: (507) 387 -9201
Group Contact Person: Judy L. H l s t Phone 6 5 1- 8 - 448
Title: D eputy .. ClerkLF to r'FAX: 651 -439 -0574
Street Address /Box 14168 O Park Bl N,, P, Box 2007
city /state /zip : Oak Park He MN 55082-2007
PLEASE RETURN THIS FORM I T : Wells Fargo Bank Minnesota, N.A.
At n: Jesse Christianson
P.O. Box 1
Mankato, IVIN 56002-0
South Central Bernice Cooperative Insurance Pooling
BLUE CROSS and BLUE SHIELD OF MINNESOTA
Automated Clearinghouse (ACH) Authorization Agreement
Blue Cross and Blue Shield of Minnesota BCBSM is hereby authorized to charge our account at wells
Fargo Bank Minnesota, National Association; Mankato, Minnesota through the Automated
Clearinghouse AC for our health insurance weekly claims payments.
Health insurance pool group number: Medical CI 15 710 Dental XG 202 -00
Group tare: City of oak Park heights
Bank name: Wells Fargo Bank Minnesota, National nal Association} Mankato, MN
Bank contact; Jesse Christianson 50 387-9252
Bank ABA routing number: 09100001
r
Wells Fargo Bark account number: 0671890887
AUTHORIZING SIGNATURES; The name(s) and signature( bel must match those on the signature
card at WELLS FA GO BANK as Identified above.
Judy L H oist Ki axe
_ �Fi�ww1t
{Pri ted Authorized I me ), (Printed Authorized Name)
1
s'natr- st natur
'✓
7/6/01 7/6/01
(Dat signe
{Date Signed}
(Printed Authorized Name)
(Signature)
(Date Signed)
NOTE, D ells Fargo Bark may assign this Agreement to any successor by merger, consolidation or corporate
reorganization.
Group Contact Person:
Title:
Street Address
City/State/Zip-
y L. Ho ist~ Phone- 651 -- 439 -44
Deputy Clerk/Finance irec o A : 651-439-0574
1 41 oak Park Blvd. N. , P .O. Box 2007
Oak Pa Heights, MN 5508? -2007
PLEASE RETURN THIS FORM To: wells Fargo Bark Minnesota, N.A.
Attn: Jesse Christianson
P.O. Box 168
M ankato, MN 56002-01
Certificate of A uthorit y
(Deposits, Credit a nd Related
Bank raafrre COtO Date
wells Fargo Bank Minnesota, National 300 07/02/2001
As s ociat i on Branch number � Oost center
133 9201
Officer ,mine officer number Phone number
Scott Ord.ahl X1783 5473879216
Account nuMberW
0671890887
Wells Fargo Bank Minnesota, National Association , ( "Bank "]
Customer's legal name
City of oaf. Parr Heights
doing business as
Customer Type (Check Box):
❑ Corporation
❑ Partnership
❑ Limited Partnership
❑ Sole Proprietor
❑ Mon- Profit Corporation
❑ Unincorporated Association
❑ Limited Liability Compan
❑ Limited Liability Partnership
❑ Professional Corporation
❑ Trus t
("Customer ")
TIIVIEIN 410941681
Federal, State or Local Government Unit or
Government Agency
❑ Tribal Government Unit or Tribal Government Agency
❑ Other
Customer organized under the laws of MN
(i175e►7 name of jurisdiction)
The person(s) signing below certifies to the Bank that:
N If the customer is not a trust or a sole ,proprietor, the governing body of the Customer has by resolution, agreement or other legally
sufficient means, named the Bank as the Customer's depository and has authorized and aaproved the terms of this Certificate in
its own or any representative capacity in which it is acting, or
(ii) if the Customer is a trust, that the undersigned islare all of the trustees] of the trust and the trustee(s) islare duly authorized to
execute this Certificate.
The person(s) signing below also certifies to the Bank that.
T. Any one of the persons whose names, any applicable titles and specimen signatures appear in the Signature Capture section is
authorized on such terms, conditions and agreements as the Bank may at any time require to:
a. Enter into agreements with the Bank for products and/or services now or hereafter offered by the Bank, and to amend, extend,
supplement, terminate and otherwise in any manner act with respect to such agreements ( "Agreements ") on such terms and
conditions as the Bank may at any time require,
b. Establish one or more accounts with the Bank in the name of the Customer;
c. Sign or otherwise authorize or endorse for deposit, cashing or collection, checks, drafts, ,payment orders, or other orders or
instructions for payment, transfer or withdrawal (collectively "Withdrawals ") from the Customer's account(s), including but not
limited to, those payable to the individual order of any person signing or otherwise authorizing the Withdrawals and those payable
to the Bank or to any other person for the benefit of any person who signed or otherwise authorized such Withdrawals;
d. Give instructions to the Bank in writing (whether signed manually, by use of a facsimile, or by a mechanical device), orally, by
telephone or by any electronic means in regard to the payment of funds and transaction of any business relating to the
Cus tom er`s account(s) or agreements, and the Bank is authorized, directed and shall be indemnified and held harmless by the
Customer for acting in accordance with any such instructions;
e. Designate each account accessible with an Instant Cash or Instant Cash and Check card and each person in whose name a card
will be issued,
f. Purchase time accounts, whether certificated or not;
g. Enter into agreements for safe deposit or safekeeping, cash management, wire or other funds transfer, commercial depository
and other deposit account related services; and
h. Delegate their authority to another person (s) or revoke such delegation, in a separate signed writing delivered to the Bank unless
the Customer is a trust.
2. If any Withdrawal authorization requires communication of a code to the Bank, and the code is communicated, the Withdrawal will
be binding on the Customer regardless of who communicates the code.
S. The Customer has received a copy of the Bank's documents describing the terms, conditions, availability of fends and fees for the
Customer's account(s) and agrees to be bound by them.
4. In addition, any one, unless otherwise provided below, of the person(s) 17arned in this Certificate may on the Customer`s behalf, and
without limitation:
a. negotiate and procure loans, lines and other extensions of credit, letters of credit and related services from the Bank in any fora,
and.in amounts and on terms as the person or persons shall determine,
b... discount, sell, assign, transfer, mortgage or pledge to the Bank any property nova, or hereafter owned by the Customer for such
consideration as the persons) deems] a ppropriate or as security for the payment or performance of any debts, liabilities or
obligations to the Bank,
e. unconditionall guarant y pa yment of any indebtedness owed to the Bank b y any person
d. apply for issuance of letters of credit and related products and services for the account of the Custorrrer or waive any letter of
credit discrepancies or nonconformitres and execute lease inventory notes and assignments of leases on behalf of the Customer,
e. sign in the name of the Customer any instrument or document deemed necessary or required to carry out the authority contained
in this Certificate; and
f. subordinate to the Bank any interest of the Customer in any instrument or any other asset belonging to the Customer as the
persons) may deer,, appropriate.
5. The information provided on this Certificate is correct and complete, the persons whose names appear below in the Signature
Capture section hold any positions indicated, and the signatures appearing opposite their names are authentic, official signatures.
B. The Bank is authorized to inquire at any time about any person named below and in the Signature Capture section with check arrdlor
credit reporting services and to share this information and other information about the Customer and the Customer's account(s) with
any direct or indirect affiliate or subsidiary of the Bank.
7. All transactions described in this certificate, or �nrhich would have subsequently been authorized by an Agreement authorized by
this certificate, conducted by or an behalf of the Customer error to delivery of this Certificate are in all respects ratified, approved
and .confirmed.
ZND
1 8145 (2-00-22106-J)
8. This Certificate is in effect on the date indicated below and shall remain in effect until the Bank receives the Customer's written
notice of its revocation and has had a reasonable opportunit to act on such notice.
9. If the Customer is a tribal g overnment or tribal government a the Customer waives Soverei Immunit with respect to all
matters directl or indirectl referred to in this Certificate, and submits to the jurisdiction of, and the Bank me y brin an le
proceedin directl or indirectl relatin to a matter referred to this Certificate, In a state or federal court.
DATE.- ()7/02/2001
CertifiedlA
Signature: Si a Lure:
Name: Ju Wolst Name:
Title: --Lfjinance) Title:
Imprint Seal (if an
AUTHORIZED SIGNERS - Check the appropriate box and then complete the desi Si Capture section(s). If neither box is
checked and one of the Signature Capture sections is left blank the Bank will be authorized to treat the sections as havin been
completed identically.
❑ Complete "Deposits and Related Services Onl section.
El Complete both of the followin sections but if either section is blank and the other is completed, the Bank will be authorized to
treat the sections as havin been completed identicall
If the customer is a sole proprietor, an Authorized Si named below shall hereb be appointed, as the Customer's attorne
for the purpose of exercisin the powers granted b this Certificate, and this power of attorne shall continue to be effective if the
Customer becomes disabled or incompetent and until the Bank receives actual notice of this Certificate's termination.
SIGNATURE CAPTURE- Deposits and Related Services Onl
Authorized Si (Onl one si is re
Name Title (if anv)
Jud L. Holst
477-62-::5070
Kimberl Damper
/I/ / (