Postal Code
Social Insurance Number
Home Telephone
Business Telephone
( )
( )
The Registered Owner(s) signing below authorize(s) and direct(s) Mackenzie Financial Corporation (“Mackenzie”) and, for segregated funds, The Great-West Life Assurance Company, to reflect
on its records the assignment of securities or units of one or more mutual or segregated funds to and in favour of the Lending Institution whose name appears in Section 3, under the terms
and conditions set out on this application form and on the reverse side of this form.
Business Telephone:
( )
Last Name
Name of Lending Institution:
Branch Code:
Transit No:
Officer Name:
Officer Name:
Day Month Year
Day Month Year
Officer Signature:
Officer Signature:
Day Month Year
Acknowledgement and Direction by Registered Owner:
Mackenzie Account Number
Joint Registered Owner:
Social Insurance Number (Joint Owner)
First Name & Initials
Last Name (Joint Owner)
First Name & Initials (Joint Owner)
1= Mr.
2= Mrs.
3= Miss
4= Ms.
5= Dr.
Mackenzie Investments
180 Queen Street West, Toronto, Ontario M5V 3K1
Terms and Conditions
1.0 This form shows an assignment to a Lending Institution of:
(a) a specific number of securities of specified mutual funds and labour sponsored investment funds managed by Mackenzie, or units of segregated
funds administered by Mackenzie for The Great-West Life Assurance Company (“Great-West Life”).
(b) For purposes of segregated fund contracts, the terms “security” and “securities” means insurance contracts, and where applicable, units of
segregated funds offered under insurance contracts. If the assignment applies to segregated funds, then references to Mackenzie on the face of
the application and in sections 2.1 and 2.2 shall include Great-West Life, and Mackenzie shall act as agent of Great-West Life with respect to the
administration of the segregated fund contract.
(c) number of securities in certain funds managed by Mackenzie and included in Mackenzie’s Portfolio Service Accounts corresponding to the dollar
value specified on the reverse side of this form. Upon receipt of assignment instructions, Mackenzie will calculate the number of securities of the
funds held within the Portfolio Service Accounts. The Registered Owner and Lending Institution will be given notice by Mackenzie of the particular
funds and the number of securities involved.
NOTE: Except in relation to the Portfolio Service Accounts, specific dollar values of fund securities should not be filled in and this form will not
be accepted by Mackenzie if such a specification is made.
Assigned Securities” means the specified number of securities or units of specified funds, excluding income, dividends, distributions, allocations
and earnings on such securities or units on such securities. If option (c) is indicated, “Assigned Securities” shall include the securities in the funds
in the relevant portfolio under the Portfolio Service Accounts which result from any rebalancing of such portfolio from time to time. It is specifically
acknowledged by the Registered Owner and, by its authorization hereof, by the Lending Institution, that the ordinary course of the operation
of the Portfolio Service Accounts will result in changes from time to time in the composition of the Assigned Securities held in portfolios
under the Portfolio Service Accounts both as to the specific mutual funds in which such securities are held and as to the absolute and relative
numbers of such securities within the portfolio. At any particular time, the composition of the Assigned Securities will be a function of the
operation of the Portfolio Service Accounts and will not necessarily be similar to the composition of the Assigned Securities as at the date of
the acceptance of this instrument by Mackenzie.
1.1 For Assigned Securities in the Portfolio Service Accounts, the Lending Institution acknowledges that Mackenzie is authorized to withdraw from the
account fees as indicated in the prospectus.
2.0 By signing this form, the Registered Owner(s) acknowledge(s):
2.1 that Mackenzie is relying on the information provided on the reverse of this form and is not required to inquire into the security or other arrangements
made between the Registered Owner(s) and the Lending Institution, and shall not be deemed to have or to have acquired any knowledge of such
arrangements solely by reason of its acceptance hereof; and
2.2 that Mackenzie may rely, without further inquiry, upon the signature of any representative of the Lending Institution as evidence of due authority to act
on its behalf, provided that such signature is guaranteed by a branch manager or authorized signing officer of the Lending Institution, with respect to
the Assigned Securities.
3.0 Mackenzie will process a request for redemption of some or all of the Assigned Securities only on receipt of a proper written authorization from the
Lending Institution, and will direct the proceeds of such redemption as set out in such authorization. Notwithstanding the previous sentence, and only
where option (c) has been indicated on this form, Mackenzie will process transfers, redemptions and reissuances between funds from time to time in the
normal course of operation of the Portfolio Service Accounts.
4.0 Mackenzie will not:
4.1 issue certificates representing any or all of the Assigned Securities; or
4.2 consider the assignment terminated or modified until Mackenzie has received written notice from the Lending Institution which (i) makes specific
reference to the name(s) of the Registered Owner(s) and the affected Mackenzie account number and (ii) clearly indicates either the desired modification
or the intention of the Lending Institution to terminate the assignment hereunder and to authorize Mackenzie to resume dealing with the Assigned
Securities on the instructions of the Registered Owner(s) alone.
Nothing in this form affects the terms of any agreement governing the Assigned Securities or dealings by Mackenzie or the Registered Owner(s) with
the Assigned Securities, including any relevant management agreement, distribution agreement, prospectus, information folder, insurance contract, or
declaration of trust, or affects Mackenzie’s right to collect fees or other amounts to which it is entitled from the designated account or otherwise.
AP1001 03212 11/16
Mackenzie Investments
 Queen Street West,
Toronto, ON MV K
TEL 1-800-387-0614
FAX 1-866-766-6623
E-MAIL service@mackenzieinvestments.com
WEB mackenzieinvestments.com