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Fillable Printable Form 625-011-000

Fillable Printable Form 625-011-000

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)
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
Address
City State Zip
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
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