Trust Account No.: _ Financial Institution:_ Street Address: _ City:_ State:_ Zip:_ Trust Account No.: _ Financial Institution:_ Street Address: _ City:_ State:_ Zip:_ IDAHO ESCROW AGENCY AUTHORIZATION TO EXAMINE TRUST ACCOUNTS To: Idaho Department of Finance, Securities Bureau For: _ Escrow Agency Company Name The undersigned, a principal officer or authorized signer of the above applicant/licensee, hereby certifies that such firm has established and maintains a trust account(s) at a bank authorized to conduct business in Idaho, and that each trust account held for this purpose is correctly identified below: The undersigned hereby authorizes the Director of the Idaho Department of Finance to examine the above described trust account(s). The undersigned further authorizes the above listed financial institution(s) to release the following information to the Director of the Idaho Department of Finance in the event any properly payable instrument is presented against an identified trust account containing insufficient funds, whether or not the instrument is honored: a) The name of the financial institution b) The identity of the escrow agent c) The account number d) Either the amount of the overdraft and the date created or the amount of the returned instrument and the date returned. The undersigned further authorizes the above listed financial institution(s) to release to the Director information relating to the trust account(s) listed above, such information to include all account records and information. The undersigned acknowledges responsibility to notify the Department of any change of financial institution. _ _ signature of officer date _ _ print officers name title IDAHO DEPARTMENT OF FINANCE Securities Bureau 800 Park Blvd, Suite 200, Boise, ID 83712 Mail To: P.O. Box 83720, Boise ID 83720-0031 Phone: (208) 332-8004 Fax: (208) 332-8099 Last update 2/4/2015Page 1 of 2 FINANCIAL INSTITUTION VERIFICATION OF TRUST ACCOUNT Account No.:_ Account No.:_ Date established:_ Date established:_ Bank:_ print name of financial institution Verified by:_ Verified by:_ print bank representatives name print bank representatives name Signature:_ Signature:_ Title:_ Title:_ Date:_ Date:_ (Seal) IDAHO DEPARTMENT OF FINANCE Securities Bureau 800 Park Blvd, Suite 200, Boise, ID 83712 Mail To: P.O. Box 83720, Boise ID 83720-0031 Phone: (208) 332-8004 Fax: (208) 332-8099 Last update 2/4/2015 BANK SIGNATURE MUST BE NOTARIZED Signed and sworn before me by: _ print bank representatives name On behalf of: _ Name of bank or financial institution this _ day of _ 20_ _ signature of Notary Public Notary Public in and for the State of _ County of _ Date Commission Expires: _ Page 2 of 2