AUTOMOBILE CLUB ASSIGNMENT OF CERTIFICATE OF DEPOSIT AS SECURITY (pursuant to § 722.005, Tex. Trans. Code Ann.)
I, (We) ____________________________________, ________________________________________ (Assignor's Name) (Assignor's Address)
(______)______________________, hereafter assignor, for the benefit of _____________________________ (Assignor's Phone)
____________________________________________, ______________________________________________ (Name of Automobile Club) (Address of Automobile Club) do hereby assign to the Secretary of State of the State of Texas all right, title and interest of the assignor in and to:
CD No. ______________________ for $_____________________ issued by _______________________ (name of institution) _______________________, _________________________________, an institution insured by the (address of institution) Federal Deposit Insurance Corporation.
THIS assignment will satisfy the requirements of TEX. TRANS. CODE ANN., § 722.005 when the Certificate of Deposit is received. THIS Certificate of Deposit shall be held by the State of Texas and is payable to the favor of the State of Texas for the use and benefit of the state or any injured party, by reason of the above-referenced Automobile Club's failure to faithfully perform in the selling or rendering of automobile club services and for failing to pay any fines or penalties levied against it for not complying with the provisions of the Automobile Club Services Act, Tex. Trans. Code §§ 722.001 et seq. THIS assignment shall remain in full force and effect until expressly withdrawn by assignor with the approval of the Secretary of State.
________________________________________________ (Assignor's Signature) 1
STATE OF ___________________ ) COUNTY OF_________________ )
Sworn to and subscribed before me by ____________________________on the _____ day of (Name of Assignor) ___________________, ___________.
____________________________________ Notary Public Signature (Notary Seal) ____________________________________
Printed Name of Notary Public
My Commission Expires
___________
<<<<<<<<<<<>>>>>>>> The Financial Institution named herein acknowledges this assignment.
_____________________________________ Signature of Officer _____________________________________ Printed Name & Title <<<<<<<<<<<<<<<>>>>>>>>>>>>>>>
_______________________ Date
RECEIPT OF SECURITY AND DIRECTION TO PAY EARNINGS Receipt is acknowledged of the above assignment. The financial institution is hereby authorized and directed to pay any earnings from the C.D. to the assignor. DATE:_____________________________
________________________________________ Signature (for the Secretary of State) ________________________________________ ________________________ (Printed Name) (Title)
FORM 2603 8/2/99
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