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SLGSafe Form Instructions

4144-5: Application for Internet Access

The 4144-5 form should be filled out every time a user is added, deleted, or renewed.

Page One:

  • Include the ABA if you are acting as Trustee bank or DDA bank.
  • Use your Tax Identification Number (TIN) if you are a State and Local Government entity, bond counsel, underwriter, or investment firm.
  • Read the legal requirements of gaining access to SLGSafe.

Page Two:

  • Fill out the information concerning the business address of the organization. This should be the address of the users that are being added or deleted. NOTE: If you are adding or deleting users from different locations, fill out a separate form for each location and attach the user acknowledgments to the corresponding application form.
  • Provide access administrator and backup administrator information, including e-mail addresses.
  • Fill in the number of user acknowledgments attached for the business address on the form.
  • Sign and date the form. The access administrator or backup administrators are the only people authorized to sign the form. If this is the initial application for your organization, both the access administrator and the backup must sign the form.
  • Include a corporate seal, signature guaranteed stamp, or medallion stamp every time you submit this form.

NOTE: The Special Investments Branch (SIB) will only accept original signatures on the application, user acknowledgment, and template. SIB will not accept faxed copies of these forms.

4144-6: User Acknowledgement

  • The name of the organization should be entered in the first paragraph.
  • If the user does not have an e-mail address, call SIB at 304-480-5299 for more information.
  • The user should sign and date the form.
  • If the access administrator or backup administrator also completes a user acknowledgment, both administrators should sign the 4144-5 Application for Internet Access.

4144-7: Template Worksheet

This form is optional. The access administrator fills out only the areas of the form that the organization wants to be included on their SLGS cases.

NOTE: The access administrator should sign and date one template form for each location used. This person should also tell SIB which users are to be attached to each template.