Public Depositor Annual Report "*" indicates required fields Step 1 of 4 25% INSTRUCTIONS FOR COMPLETING THE PUBLIC DEPOSITORS ANNUAL REPORT Please use the following instructions when completing the annual report form to ensure correct information is being supplied. If you have any further questions concerning this report form, please contact the Treasury staff at (601) 359-2336. Written inquiries may be sent via e-mail to collateral@treasury.ms.gov. DUE DATE: No later than thirty (30) days following your fiscal year end. SCHEDULE A – GENERAL INFORMATION Report of Fiscal Year Ending is the fiscal year that this report covers. Public Entity Name is the official name of your office. Political Subdivision Type - example; city, county, school district, utility district, community health agency, library, hospital, etc. Mailing Address of Principal Offices is your mailing business address. Telephone Number is your primary business telephone number. Fax Number is your primary fax telephone number. Contact Person(s) is the person(s) the State Treasurer may contact. E-Mail Address is the email address of the person(s) listed as the contact person. SCHEDULE B – PUBLIC DEPOSITS HELD Public accounts can be reported by either uploading a listing using the file upload option, or by filling in the required information in this form. When uploading a listing, please provide detailed information, as requested, per bank on any accounts that you may use for public funds. Account Name is the name by which the account is listed. Account Number is the number assigned by the bank to this account. Federal Tax Identification Number s the tax identifying number you have been assigned for this account. Type of Account is the category this account falls within. The categories are Demand (D), Time (savings accounts and all other interesting bearing accounts) (T), and Certificate of Deposit (CD). Account Balance is the balance of the account as of fiscal year end. As required by Miss. Code Ann. §27-105-5 (6) (b), every public depositor is required to notify the State Treasurer’s office no later than thirty (30) days following its fiscal year end of its name, address, tax identification number and listing of deposit accounts.SCHEDULE A – GENERAL INFORMATIONReport of Fiscal Year Ending*Select an FY End12-31-202503-31-202604-30-202605-31-202606-30-202608-31-202609-30-202610-31-2026Public Entity Name*Political Subdivision Type*Mailing Address* Mailing Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact Person* First Last Phone Number*Fax NumberEmail* Alternate Contact Person* First Last Alternate Contact Phone Number*Alternate Contact Email* SCHEDULE B - PUBLIC ACCOUNTS*Please upload a listing or describe below all public accounts being used by depositor/depositors for public funds. Please upload one form per depositor. Upload report Fill in form Please provide the following detailed information per bank on any accounts that you may use for public funds: Bank Name is the institution(s) at which you bank. Account Name is the name by which the account is listed. Account Number is the number assigned by the bank to this account. Federal Tax Identification Number is the tax identifying number you have been assigned for this account. Type of Account is the category this account falls within. The categories are Demand (D), Time (savings accounts and all other interesting bearing accounts) (T), and Certificate of Deposit (CD). Account Balance is the balance of the account as of fiscal year end.File upload* Drop files here or Select files Accepted file types: pdf, Max. file size: 40 MB, Max. files: 6. This form accepts a maximum of 20 entries. If you have more than 20 public accounts to describe, please upload your report.1.Bank*Account Name*Account #*Federal Tax ID*Type of Account*Select an accountDemandTimeCertificate of DepositAccount Balance*Add Bank #2 Add 2.Bank*Account Name*Account #*Federal Tax ID*Type of Account*Select an accountDemandTimeCertificate of DepositAccount Balance*Add Bank #3 Add 3.Bank*Account Name*Account #*Federal Tax ID*Type of Account*Select an accountDemandTimeCertificate of DepositAccount Balance*Add Bank #4 Add 4.Bank*Account Name*Account #*Federal Tax ID*Type of Account*Select an accountDemandTimeCertificate of DepositAccount Balance*Add Bank #5 Add 5.Bank*Account Name*Account #*Federal Tax ID*Type of Account*Select an accountDemandTimeCertificate of DepositAccount Balance*Add Bank #6 Add 6.Bank*Account Name*Account #*Federal Tax ID*Type of Account*Select an accountDemandTimeCertificate of DepositAccount Balance*Add Bank #7 Add 7.Bank*Account Name*Account #*Federal Tax ID*Type of Account*Select an accountDemandTimeCertificate of DepositAccount Balance*Add Bank #8 Add 8.Bank*Account Name*Account #*Federal Tax ID*Type of Account*Select an accountDemandTimeCertificate of DepositAccount Balance*Add Bank #9 Add 9.Bank*Account Name*Account #*Federal Tax ID*Type of Account*Select an accountDemandTimeCertificate of DepositAccount Balance*Add Bank #10 Add 10.Bank*Account Name*Account #*Federal Tax ID*Type of Account*Select an accountDemandTimeCertificate of DepositAccount Balance*Add Bank #11 Add 11.Bank*Account Name*Account #*Federal Tax ID*Type of Account*Select an accountDemandTimeCertificate of DepositAccount Balance*Add Bank #12 Add 12.Bank*Account Name*Account #*Federal Tax ID*Type of Account*Select an accountDemandTimeCertificate of DepositAccount Balance*Add Bank #13 Add 13.Bank*Account Name*Account #*Federal Tax ID*Type of Account*Select an accountDemandTimeCertificate of DepositAccount Balance*Add Bank #14 Add 14.Bank*Account Name*Account #*Federal Tax ID*Type of Account*Select an accountDemandTimeCertificate of DepositAccount Balance*Add Bank #15 Add 15.Bank*Account Name*Account #*Federal Tax ID*Type of Account*Select an accountDemandTimeCertificate of DepositAccount Balance*Add Bank #16 Add 16.Bank*Account Name*Account #*Federal Tax ID*Type of Account*Select an accountDemandTimeCertificate of DepositAccount Balance*Add Bank #17 Add 17.Bank*Account Name*Account #*Federal Tax ID*Type of Account*Select an accountDemandTimeCertificate of DepositAccount Balance*Add Bank #18 Add 18.Bank*Account Name*Account #*Federal Tax ID*Type of Account*Select an accountDemandTimeCertificate of DepositAccount Balance*Add Bank #19 Add 19.Bank*Account Name*Account #*Federal Tax ID*Type of Account*Select an accountDemandTimeCertificate of DepositAccount Balance*Add Bank #20 Add 20.Bank*Account Name*Account #*Federal Tax ID*Type of Account*Select an accountDemandTimeCertificate of DepositAccount Balance* SCHEDULE C – CERTIFICATIONELECTRONIC SIGNATURE REQUIRED* I herby certify that I have read the foregoing facts and the attachments provided and that they are true.Preparer Signature*Title*Date
