Fillable Printable Form 625-011-000

Form 625-011-000

F625-011-000 reassignment of savings account or time deposit 3-08

Department of Labor and Industries

Contractor Registration Section

PO Box 44450

Olympia WA 98504-4450

REASSIGNMENT OF

SAVINGS ACCOUNT

OR TIME DEPOSIT

This form is to be used to change the business name of the assignor, the account number, or the amount of

the assignment. SECTION 1 must be completed

, and one or more of the other appropriate sections.

The back of this form must be signed and notarized

, and the original of this form must be submitted to

the Contractor Registration Section

REGISTRATION NUMBER: ____________________ UBI NUMBER: _________________________

SECTION 1. ORIGINAL ACCOUNT INFORMATION – As on file with L & I

This reassignment is for the purpose of fulfilling the requirements of RCW 18.27.040. The undersigned

does hereby assign, transfer and set over to the State of Washington all right, title and interest to

____________________ thousand dollars ($_________) of Savings Account number (OLD account

number) ______________in the (bank) ______________________ for the purpose of all claims against

(Registered Business name under which original assignment was made) ___________________________

that are within the provision of RCW 18.27.040 arising from (original deposit date) ________________

through the future, provided the claims are timely made in accordance with that statute.

TO MAKE CHANGES TO THE ORIGINAL ACCOUNT INFORMATION

COMPLETE THE APPROPRIATE SECTION(S) BELOW

SECTION 2. BUSINESS NAME:

The same deposit as described in Section 1 shall be subject to claims that re covered by RCW 18.27.040

arising against (succeeding assignor, new business name ______________________________________a

(general/specialty) _______________________contractor. By virtue of this reassignment the State of

Washington, Contractor Registration Section has full power and authority to demand, collect and receive

the deposit and to give receipt of acquittance thereof for the purposes prescribed by RCW 18.27.040. It is

further understood and agreed that the bank agrees to hold the money in this account until it receives the

release of this assignment from the Contractor Registration Section. The same will release the deposit to

the State of Washington within 30 days on demand with no other conditions of release.

Original assignor (signature)

SECTION 3. ACCOUNT NUMBER CHANGE.

The same deposit as described in Section 1 shall be subject to claims that are covered by RCW 18.27.040

arising against this Business, a (general/specialty) ___________________contractor, in the new Savings

Account number (NEW account number) _______________. By virtue of this reassignment the State of

Washington, Contractor Registration Section has full power and authority to demand, collect and receive

said deposit and to give receipt of acquittance thereof for the uses and purposes prescribed by RCW

18.27.040. It is further understood and agreed that the bank agrees to hold the money in this account until

the release of this assignment is received from the Contractor RegistrationSection. The deposit will be

released to the State of Washington within 30 days on demand with no other condition of release.

PAGE 2 OF THIS FORM MUST BE SIGNED AND NOTARIZED BY BANK PERSONNEL

Signature of assignor

RESET

F625-011-000 reassignment of savings account or time deposit page 2 3-08

SECTION 4. THE AMOUNT OF THE SAVINGS ACCOUNT INCREASED:

By this reassignment, the undersigned changes the amount of the deposit described in Section 1 to (new

amount of deposit) ____________________thousand dollars ($____________). This deposit shall be

subject to claims that are covered by RCW 18.27.040 arising against the business which is a

(general/specialty) ____________________contractor. By virtue of this reassignment the State of

Washington, Contractor Registration Section has full power and authority to demand, collect and receive

said deposit to give receipt of acquittance thereof for the uses and purposes prescribed by RCW

18.27.040. It is further understood that the bank hold the money in this account until release of this

assignment is received from the Contractor Registration Section. This deposit will be released to the

State of Washington within 30 days on demand with no other condition of release.

SECTION 5. THE FINANCIAL INSTITUTION CHANGE.

The same deposit as described in Section 1 shall be subject to claims that are covered by RCW 18.27.040

arising against this Business, a (general/specialty) _____________________________ contractor, in the

new Financial Institution (new name of bank) ______________________________________________

by virtue of this reassignment the State of Washington, Contractor Registration Section has full power

and authority to demand, collect and receive said deposit and to give receipt of acquittance thereof for the

uses and purposes prescribed by RCW 18.27.040. It is further understood and agreed that the bank agrees

to hold the money in this account until the release of this assignment is received from the Contractor

Registration Section. The deposit will be released to the State of Washington within 30 days on demand

with no other condition of release.

IMPORTANT: The notary section must be completed by two (2) bank personnel. One to sign

and another person to notarize the other’s signature.

By signing below I certify that the savings account described in “Section 1” has been changed as

noted in “Sections 2 through 5”.

NOTARY PUBLIC SIGNATURE BANK PERSONNEL SIGNATURE

NOTE TO ASSIGNOR: This account will not be released until TWO Years after the last date of the

Certificate of Registration, provided, there are no court judgments or otherwise disposed of summons and

complaints against the deposit. A written request, signed by the assignor must be submitted to the

Contractor Registration Section to obtain release of this account.

Signature of assignor

Signature of depositor

Signature of assignor

Address

City State Zip

SUBSCRIBED AND SWORN TO BEFORE ME THIS

DATE

Printed Name Title

Notary Public in and for the State of Signature of authorized personnel of bank

Residing at Bank address Bank phone #

My commission expires City State ZIP