General Information
Date of Request
12/15/2018 7:22 AM
Action Required
Control Number  (if known or for closing an account)
Agency Information
Batch Agency Code
Financial Agency Code
Batch Agency Name
Contact Information
Requestor Name / Title
Requestor Email Address
Requestor Phone Number Fax Number
Authorized Signer / Title
Email Address of Authorized Signer
Authorized Signer Phone Number Fax Number
Is Authorized signer a State Employee?
Banking Information
Bank Name
Bank Account Number
Bank Account Title
Federal Tax ID Number for Bank Account
Source of Funds
Account Purpose
Account Type
Estimated account balance
Will this account generate investment earnings?    
Electronic Signature
By my electronic signature, I do hereby request the establishment of a State of Maryland Agency Bank Account.
I certify I have reviewed all the requirements for the operations of this account
and will insure that proper Internal Control Guidelines will be followed.
Enter the security code to submit.