ARKANSAS STATE TREASURY MONEY MANAGEMENT TRUST

Please complete this form and return to the Arkansas State Treasury's Office via email. Email: MMTrust@artreasury.gov Contact: STMMT Administrator (501-682-1419)

Participant Name: ____________

Request Date: ____ Transaction Date: ______

Participant's Phone Number: ____________

Participant's Email: ____________

Withdrawal Amount: ____________

From STMMT Account Number: ____________

To Bank Name: ____________

Bank Routing Number: ____________

Bank Account Number: ____________

Authorized by:

Signature

Title

Please Print Name

Date

FOR TRUST USE ONLY

Ticket # __

Correspondent

Bank Name ____________

Bank T/R # ____ Account Balance ______

Correspondent Bank T/R# ____________