TDA 100557 04/20Page 1 of 2
PO Box 2760
Omaha, NE 68103-2760
Fax: 866-468-6268
RETURN TO: PO Box 2760, Omaha, NE 68103-2760, Fax: 866-468-6268, or attach to a secure email using the Message Center in your account.
Return this signed form and a recent DRS Advice Notice or Statement (dated within 90 days) to request delivery from a transfer agent
using the Direct Registration System (DRS). It can take up to five business days for a transfer agent to deliver the requested shares.
Additional documentation may be required for some Over-the-Counter/Bulletin Board (OTC/BB) securities before a request is submitted.
You will be notified if this information is required.
1. TRANSFER AGENT ACCOUNT INFORMATION
Account Number (Required): (Only One per form) Registration/Title: Security (Name, Symbol, or CUSIP):
Social Security/Tax ID Number: 2nd SSN/TIN (If applicable):
Please confirm the transfer agent has the correct SSN/Tax ID on file. The agent will reject the request if there is a mismatch of SSN/Tax ID.
Account Type (select one):
M
Individual (non- IRA) M Joint M Trust M Simple IRA M SEP IRA M Traditional/Rollover IRA M Roth IRA M Beneficiary IRA
M
Beneficiary Roth IRA M Estate M UGMA/UTMA M Corp/Business M 403B M Qualified Plan M Other: _____________________
2. TRANSFER INSTRUCTION (REQUIRED) (CHECK ONLY ONE BOX)
M All whole, book-entry shares, liquidate any fractional share, and keep the transfer agent account open. (A)
If you wish to close the delivering account, please contact the transfer agent once the transfer is completed.
M
All whole, book-entry shares, do not liquidate fractional, and keep the transfer agent account open. (P)
M Transfer only _________________ whole shares.
Transfer agents may
assess a fee to liquidate
a fractional share.
3. TD AMERITRADE AUTHORIZATION TO REQUEST TRANSFER—ALL OWNERS LISTED AT THE TRANSFER AGENT
MUST SIGN
Unless otherwise indicated in the instructions above, please transfer, in-kind, all assets into my account with TD Ameritrade. I understand that
the extent any assets in my account are not readily transferable, with or without any penalties, such assets may not be transferred within the
time frames required by applicable regulations. I understand I will be contacted by the carrying and/or receiving firm with regard to any assets
that are not transferable. I authorize the Transferor to deduct any outstanding fees due to transfer from the credit balance, or, if the credit
balance in the account is insucient, I agree to satisfy any outstanding fees. If this TD Ameritrade account is a qualified retirement account, I
have amended the applicable plan to designate the successor custodian. Alternatively, if this TD Ameritrade account is an Individual Retirement
Account (IRA), I have adopted an IRA plan so that it names the successor custodian.
✗
Owner's Signature:
Date:
✗
Co-Owner's Signature (If applicable):
Date:
✗
Co-Owner's Signature (If applicable):
Date:
4. REGISTRATION DIFFERENCES & ONE-AND-THE-SAME VERIFICATION
Registration Dierence—Individual to Joint Account
If the account you are transferring is in an Individual’s name and your TD Ameritrade account is a Joint Account, the transfer may result in a
reduction of full ownership. You hereby authorize a transfer from the individual account in the name of _________________________________
to the Joint account at TD Ameritrade for _______________________________________ and _______________________________________
✗
Individual Owner's Signature:
One-and-the-Same Verification
If you are transferring an account, and the name(s) at TD Ameritrade do not exactly match but are one-and-the-same person, please complete
this section. Legal documentation must be provided if requested by TD Ameritrade.
I, ________________________________________________________ (please print name), am One-and-the-Same as
_________________________________________________________ (please print name) as shown on the delivering firm account.
Please sign name BOTH ways.
✗
Signature:
✗
Signature:
A
Direct Registration System
(DRS) Transfer Form
An External Transfer Form is needed for other requests
Account Number to receive the transfer (Required):
(Only One per form) ______________________
*TDA100557*
