©2012 Charles Schwab & Co., Inc. (“Schwab”).
All rights reserved. Member SIPC.
Schwab Institutional® is a division of Schwab.
CS16756-28 (0108-0016) APP20326-05 (08/12)
*
APP20326-05
=01*
Third-Party Release Form
Investment Advisor (“IA”) Information (This portion to be completed by IA.)
IA Firm Name (please print): __________________________________________________________________________________________________________
IA Master Account Number: _____________________________________________________________ Service Team: ________________________________
The certicate indicated below is registered in a name other than that of the account. To authorize the processing of the certicate, please complete the
form below and have a notary afrm your signature.
1. Authorization
The undersigned hands you herewith _____________ shares/bonds of _________________________________________________________________________
duly assigned in blank, and requests that you place said securities in the account of:
Account Holder Name (registration exactly as it appears on the account)
Additional Account Holder Name
Additional Account Holder Name
Additional Account Holder Name
Account Number (eight digits)
whom you may, for all purposes whatsoever, treat as the sole owner(s) of said securities, and proceeds thereof.
2. Authorized Signature(s)
Signature(s) must correspond exactly with the name(s) written on the face of the certicate(s) or bond(s).
______________________________________________________________________________________________________ Date _______________________
Signature
Print Name (mm/dd/yyyy)
______________________________________________________________________________________________________ Date _______________________
Signature
Print Name (mm/dd/yyyy)
______________________________________________________________________________________________________ Date _______________________
Signature
Print Name (mm/dd/yyyy)
3. Notarization
Note: This form must be notarized.
State of ___________________________________ , County of __________________________________________
On ________________________ before me, __________________________________________________________,
(mm/dd/yyyy) (Name and Title of the Notarizing Ofcer)
personally appeared _____________________________________________________________________________ ,
(Name of Person[s] Signing Instrument)
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed
to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their
authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity
upon behalf of which the person(s) acted, executed the instrument.*
I certify under PENALTY OF PERJURY under the laws of the State of ______________________ that the
foregoing paragraph is true and correct.
WITNESS my hand and ofcial seal.
Notary Public _________________________________________ Expiration Date __________________________
(Signature of Notarizing Ofcer) (mm/dd/yyyy)
*Notaries outside of California may attach the appropriate notarizing declaration in lieu of the above.
(NOTARY SEAL)
WB
ADAMS HALL WEALTH ADVISORS LLC
