CORRESPONDENT BROKER
DEALER APPROVAL SECTION
LETTER OF AUTHORIZATION ("LOA") DATE:___/___/_____
FOR CHANGE OF OWNERSHIP
TO: (Print Name & Address of Broker-Dealer) FROM: (Print Name & Address of Customer)
_________________________________________ _______________________________________________
_________________________________________ _______________________________________________
_________________________________________ _______________________________________________
This Letter of Authorization executed by the undersigned customer serves as formal notification to transfer the cash and/or securities listed in the Assets Transfer Instructions
Section ("customer" is used as singular or plural, as applicable). DO NOT USE WHITE OUT. If necessary, cross out errors and initial corrections.
ASSETS TRANSFER INSTRUCTIONS SECTION
Purpose of this transaction is
: _____________________________________________
(Attach separate, signed and dated pages if needed)
CASH $ ____________________
NO. OF SHARES OR PRINCIPAL
AMOUNT OF BONDS
____________________________
____________________________
____________________________
____________________________
PLEASE TRANSFER THE ABOVE LISTED ASSETS
MARKET VALUE OF SECURITIES $ _______________________________________
(Approximate)
DESCRIPTION OF SECURITIES
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
From My Account Number: _______________________________In the name of: ___________________________________________________________________
To Account Number: ___________________________________ In the name of: ___________________________________________________________________
OR TO: Name & Address of Institution/Individual Receiving Assets:
If delivering to another Brokerage firm/Institution: If delivering a physical certificate or check directly to an individual(s):*
Name of Institution: ______________________________ Tax ID # or SSN# of beneficiary is required for physical stock certificate delivery.
DTC # or ABA #: ________________________________ Tax ID # or SSN#: ________________________________________________
Account Number: ________________________________ Delivery Address: ________________________________________________
Name of Beneficiary: _____________________________ _______________________________________________________________
*Indicate full title, including custodian name that should appear on the certificate
CUSTOMER SIGNATURE SECTION
The undersigned customer hereby authorizes you to transfer the above assets as indicated. In the event of a change in beneficial ownership
as a result of this authorization, the undersigned customer hereby relinquishes all rights, title and interest in said securities and/or monies and
irrevocably releases and discharges you and your clearing agent of any claims by the undersigned customer or by the undersigned customer’s legal
representatives thereto, including any disposition of such assets. Further, the undersigned customer hereby indemnifies you and your clearing agent
against any and all losses and expenses incurred by you and your clearing agent for acting upon these instructions.
FOR INDIVIDUALS (INCLUDING JOINT ACCOUNTS):
_________________________________________ _____________________________________________
___/___/_____
Print Name of Customer Signature of Customer Date
_________________________________________ _____________________________________________
___/___/_____
Print Name of Joint Customer Signature of Joint Customer Date
FOR TRUSTS, PARTNERSHIPS AND CORPORATIONS:
______________________________________________________________________________________________________________________
Print Account Title
__________________________________________________ ____________________________________________
___/___/_____
Print Name and Title of Authorized Signer Authorized Signature Date
__________________________________________________ ____________________________________________
___/___/_____
Print Name and Title of Authorized Signer Authorized Signature Date
MEDALLION STAMP SIGNATORY / NOTARY PUBLIC SECTION
(CUSTOMER’S SIGNATURE MUST BE MEDALLION STAMP GUARANTEED BY A FINANCIAL INSTITUTION IF VALUE OF ASSETS IS OVER $10,000.
ALTERNATIVELY, A NOTARIZED SIGNATURE WILL BE ACCEPTED IN LIEU OF THE MEDALLION STAMP FOR VALUES UP TO $50,000.)
State of _______________________ , County of _____________________
On this _____ day of _____________________, 20______, before me, _____________________________________________________ ,
Print Name of Notary Public/Authorized Medallion Signatory
personally appeared _________________________________________________________________ __________
Print Name(s) of Customer(s) whose Signature(s) is/are Notarized/Medallion Stamp Guaranteed
Number of Signatures Being Notarized/Medallion Stamp Guaranteed
Personally known to me or Proved to me on the basis of
satisfactory evidence to be the person(s) whose name(s)
is/are subscribed to 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.
Authorized Medallion Stamp & Signature or Notary Public Stamp & Signature
To Wedbush Morgan Securities:
Under the terms of our Clearing Agreement and the Letter of Understanding signed by the above customer, we hereby request that
you honor the instructions of our customer as stated above. We have carefully reviewed this request and the appropriate supporting documents, and we represent to you that
this request is in compliance with all applicable laws and regulations. Our firm and its principal officers (both as officers and as individuals ) jointly and severally indemnify you
against any and all losses and expenses incurred or to be incurred by you for acting upon these instructions.
__________________________________________________________
(Print Name of Principal)
_________________________________________________________ _____/______/______
Signature of Principal (or Authorized Designee) of Correspondent Broker-Dealer Date approved FORWARD ORIGINAL TO CREDIT DEPT
LOA 0506
