CB007 Government Approving Setup/Maintenance Form
page 1 of 2
1352469 08/15
ALL fields must be completed prior to submission or the form will be returned to you.
Numbers in parentheses correspond to numbers on guide sheet on next page.
Citibank
®
Government Approving Official
Setup/Maintenance Form
Note: At an Agency/Organization’s option, an Approving Official may be designated.
Section I: Instructions
1. To add, delete or change Approving Official (AO) information, the Approving Official completes Sections II and signs in Section IV,
and the A/OPC completes Sections III, and signs in Section IV. Signatures are required only if submitted by fax or mail.
2. Indicate the type of request:
•
AO Setup and CitiDirect
®
Card Management System ID Request
•
AO Setup but DO NOT issue a CitiDirect Card Management System ID
•
AO Setup and CitiDirect Card Management System ID Request for view only
3. Indicate the action you are requesting:
•
Add to AO info (Complete entire form)
•
Change AO information
(Complete Reporting Hierarchy and only the items requiring a change)
•
Delete AO info
•
Add as Alternate AO
4. Maintain a copy in the Approving Official and Agency/Organization Program Coordinator’s files.
5. Fax completed form to your Client Account Manager at 904-954-7700.
Section II: Approving Official Information (Please Print)
(1) _____________________________________________________________________________________________________________________
First Name of Approving Official (maximum of 24 characters) Middle Initial Last Name (maximum 24 Characters total))
(2) ___________________________________________________________________________ (3) _____________________________________
Agency/Organization Name (maximum 24 characters) Verification Information
(4) ___________________________________________________________________________ (5) ( ______ ) _______ - ____________________
Business Mailing Street Address Line 1 (maximum 36 characters) Business Phone
________________________________________________________________________________________________________________________
Business Mailing Street Address Line 2 (maximum 36 characters)
________________________________________________________________________________________________________________________
City State Zip Code Country
____________________________________________ (6) ( ______ ) ______ - __________ (7) ______________________________________
E-mail Address Fax Number Discretionary Code 1 (maximum 12 characters)
Section III: Reporting Parameters
Account Number: (8) _____________________________________________________________________________________________________
Reporting Hierarchy: (9) ____________ ____________ ____________ ____________ ____________ ____________ ____________
Section IV: (10) AO and A/OPC SIGNATURE (Required for paper submission)
________________________________________________________________________________________________________________________
Approving Official’s Signature Date
________________________________________________________________________________________________________________________
Approving Agency/Organization Program Coordinator’s Signature Date
_________________________________________________ ( ______ ) ______ - ____________ ( _______ ) ________ - ____________________
Full Name (Please Print) Business Phone Fax Number
PRINT
SAVE
CLEAR
page 2 of 2
Guide to Citibank
®
Government Approving Official
Setup/Maintenance Form
© 2015 Citibank (South Dakota), N.A. All rights reserved. Citi and Arc Design and Citibank are service marks of Citigroup Inc.
or its affiliates, used and registered throughout the world.
CB007 Government Approving Setup/Maintenance Form 1352469 08/15
Form used to add Approving Officials.
Section I: Instructions
Section II: Approving Official Information
1. Name of Approving Official: Approving Official’s full name — First name, middle initial and last name (maximum 24 characters total).
2. Agency/Organization Name: Please provide complete name of agency/organization of Approving Official.
3. Verification Information: Approving Official to provide identification password (i.e., a control number). This will be requested when
the Approving Official contacts Citibank Customer Service for assistance.
4. Business Mailing Street Address: Physical mailing address for the Approving Official.
5. Business Phone: Area code and business phone number.
6. Fax Number: Area code and fax number.
7. Discretionary Code 1: Please provide appropriate discretionary code where applicable.
Section III: Reporting Parameters
8. Account Number: Provide your Government-assigned account number.
9. Reporting Hierarchy: The five-digit reporting code assigned to each level within the organizational hierarchy that defines the
Cardholder’s relationship within your Agency’s reporting structure. Up to seven five-digit codes may be assigned to your Agency.
Contact your Client Account Manager for your Agency’s specific codes.
Section IV: AO and A/OPC SIGNATURE
10. AO and A/OPC SIGNATURE: Each Approving Official and Agency/Organization Program Coordinator listed must sign.
Section V: Internal Use Only
This section is for bank use only.
