TDA 139 F 10/18
Page 1 of 1
Mail or Fax to:
PO Box 2760
Omaha, NE 68103-2760
Fax: 866-468-6268
1. ACCOUNT INFORMATION
Account Number: Contact Number:
2. ELECTRONIC TRANSFER INSTRUCTIONS
▫
Charitable Gift
For tax purposes, please contact recipient of coming donation. Consult with a tax professional on any tax issues.
Please review the guidelines below to make sure your transfer can be processed.
- For all gift transfers, the date of gift is the date the transfer is completed.
If a charitable contribution, I certify that it is bona fide. TD Ameritrade Clearing, Inc. may release my name to the receiving
charitable organization unless I indicate otherwise by initialing here __________.
▫
Partial Transfer
Other than charitable contributions, if transfers are not between like-titled accounts, the third party information below must be
completed. Partial account transfers between brokerages via an electronic system.
Pursuant to the provisions of the USA Patriot Act of 2001, TD Ameritrade needs specific information from our clients regarding certain
transactions, including Third Party Transfers. For this reason, we do ask for a specific purpose for Third Party Transfers.
Please Note: Not all Third Party Transfer requests can be facilitated as the request may be outside TD Ameritrade’s scope of business.
__________________________________________________________________________________________________________________
Reason for Third Party Transfer: Relationship:
Receiving Firm Name: DTC Number:
Receiving Account Title: Receiving Account Number:
3. ASSETS TO BE TRANSFERRED
Only whole shares can be requested, as fractional shares cannot be processed. I understand that any trading could delay the processing of this request.
Symbol/CUSIP # of Shares Symbol/CUSIP # of Shares Symbol/CUSIP # of Shares
Please list additional shares from transfer on a separate piece of paper
If you would like to select a specific lot to be transferred other than your current lot relief selection, please submit a signed and dated letter of
instruction (LOI) along with your Partial Transfer Form. The LOI will need to include: Asset Description or Symbol, Number of Whole Shares,
Date Purchased and Current Cost per Share.
*If lots are not specified prior to the settlement of the transfer, your transfer default tax lot identification method will be used. Please note,
your default tax lot identification method for transfers may be dierent than what you selected for trades. To view available lots for the transfer,
please log into your account and access the Gain/Loss Report, which can be located under My Account>Gain Loss. .
I (we) authorize TD Ameritrade Clearing, Inc. to transfer the above-listed security as indicated. I understand that not all securities are eligible for
direct registration transfer.
4. SIGNATURE AND SIGNATURE GUARANTEE STAMPS (Please sign, print, and mail or fax this form to initiate the transfer request.)
✗
Account Owner’s Signature:
Date:
Signature Guarantee Stamp:
✗
Account Co-Owner’s Signature:
Date:
Transfer Out - Depository Trust and
Clearing (DTC) Transfer Form
For use when requesting a Charitable
Gift or Outbound partial transfer to
another financial institution.
*TDA139*
Investment Products: Not FDIC Insured * No Bank Guarantee * May Lose Value
TD Ameritrade, Inc., and TD Ameritrade Clearing, Inc., members FINRA/SIPC. TD Ameritrade is a trademark jointly owned by
TD Ameritrade IP Company, Inc. and The Toronto-Dominion Bank. © 2018 TD Ameritrade.
