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L I <br />O <br />O <br />1 <br />0) <br />GAS TAX SYSTEMS INPUT DOCUMENTATION <br />(80% and 20% Gas Tax Information) <br />'GAS TAX ACCOUNT # 8096 Distribution _ 2096 Distribution _ Both 8096 and 2096 _ <br />'Send funds by: WIRE CHECK POOUNON POOL ACCOUNT <br />,COMPLETE COUNTY TITLE AND ADDRESS: Check here II this reflects a change o1 address: _ <br />AREA CODE/TELEPHONE NUMBER <br />.<PLEASECONTACTY.OURBANKAIVDAREQUESTTHEFOLLOWINGINFORMA77ON <br />o NAME AND ADDRESS OF ROUTING BANK (if applicable): <br />ROUTING BANK'S ABA <br />o NAME AND ADDRESS OF BANK TO WHICH FUNDS SHOULD BE WIRED: <br />BANK ACCOUNT NUMBER <br />,NAME OF PERSON(S) AUTHORIZED TO NOTIFY US OF CHANGES IN GAS TAX RECEIPT: <br />NAME <br />TITLE <br />SIGNATURE <br />STATE OF FLORIDA <br />COUNTY OF <br />ALL CHANGES MUST BE SIGNED BY <br />AN INDIVIDUAL NAMED BY TTTLE <br />IN THE RESOLUTION, OR PREVIOUSLY <br />SUBMITTED DOCUMENTATION FORM <br />Before me personally appeared <br />known to me to be the person described In and who executed <br />the foregoing Instrument for the purposes therein expressed. <br />WITNESS my hand and official seal this <br />day of A.D 19 . <br />(SEAL) <br />Authorized Signature <br />Print or Type Name Above <br />Notary Public <br />State of Florida <br />My commission expires: <br />Date <br />dw- <br />FOR STATE BOARD OF ADMINISTRATION USE ONLY <br />CFO Approval <br />Debt Sorvico <br />• <br />Date <br />Hato <br />GL ACCOUNT/ <br />vn+c'r:l eltrn7-rocid <br />1 <br />