Pl Please visit our website at www.com.ohio.gov/real 614|466 - 4100 Fax: 614|644 - 0584 TTY/TDD: 800|750 - 0750 Anne M. Petit , Superintendent REAL ESTATE TRUST/SPECIAL ACCOUNT DECLARATION FORM All Trust or Special, non-interest bearing account information must be filed with this office utilizing this form. Trust or Special, non-interest bearing account information is verified for correctness during all Compliance Audits. This form is interactive. You may, before printing, type your responses directly onto the form. Otherwise, this form must be typewritten or printed legibly in black ink. Use this form to establish or update in the divisionds each active trust or special, non-interest bearing account held by the company. Attach a letter or statement from the bank at wactive trust or special, non-interest bearing account is held that includes the account D.B.A. name, the account number, and a statement that the account is a non-interest bearing trust or special account. COMPANY/BROKER INFORMATION BROKER NAME BROKER FI L E N U MBER BUSINESS NAME DOING BUSINESS AS (D.B.A.) NAME F I LE NUM BER MAIN BU S I NESS ADDRESS CITY STATE ZIP CODE ESCROW/EARNEST MONEY NON-INTEREST BEARING ACCOUNT INFORMATION ACTION Establishing New Account Update Current Account Information NAME OF BANK ACCOUNT NAME ACCOUNT NUM B ER BANK ADDRESS CITY STATE ZIP CODE PROPERTY MANAGEMENT NON-INTEREST BEARING ACCOUNT INFORMATION ACTION Establishing New Account Update Current Account Information NAME OF BANK ACCOUNT NAME ACCOUNT NUM B ER BANK ADDRESS CITY STATE ZIP CODE AUTHORIZED SIGNATURE DATE Be certain the attached statement from your bank indicates that the Trust or Special account(s) is non-interest bearing. COM 3692 (04/2016) Equal Opportunity Employer and Service American LegalNet, Inc. www.FormsWorkFlow.com