1
®
Registered trade-marks of Bank of Montreal, used under licence.
BMO InvestorLine Inc. is a wholly owned subsidiary of Bank of Montreal.
Member – Canadian Investor Protection Fund and Member of the Investment Industry Regulatory Organization of Canada.
Order Execution Only Account
0006-SD-E (09/2017)
MATERIAL CHANGE FORM
To ensure continuous access to your account(s), please submit the fully completed, dated, and signed original.
Account #1:
Related Accounts
#2
Transaction # _________________________________________
#3 #4
Last
First
Title
Name Name
Initials
Primary
Suite
Residence Address
No.
(No., street, P.O. Box address is not allowed)
City or
Postal
Town
Prov.
Code
Country
Marital Home Phone
Status
(area code, no.)
Citizenship
Business Phone
(area code, no.)
Email
Address
Residency for Tax purposes (Check all that apply)
Canada (You must be a resident of Canada to open Social Insurance Number (required by Canada Revenue Agency)
a BMO InvestorLine account)
U.S.
Other (please specify)
Other (please specify)
If you are using a SIN starting with a 9, please submit a photocopy of your SIN card showing a valid expiry date.
Tax Identification Number (please provide a reason if Tax Identification Number is missing)
Tax Identification Number (please provide a reason if Tax Identification Number is missing)
Tax Identification Number (please provide a reason if Tax Identification Number is missing)
Reasons for missing Tax Identification Number (TIN):
1. I have applied for a TIN but have not yet received one. 2. My jurisdiction of tax residence does not issue TINs to its residents.
Pro BMO Staff
Employment
Full-time (30 hours or more per week) Part-time (Less than 30 hours per week) Self employed Unemployed
Status
Retired (Please provide your last: occupation, employer’s name, industry, city and prov.) Casual/Contract Seasonal
Employer
Occupation
Name
Job
Industry
Title
Employer’s Address
Employer’s Phone
Number
1. Are you, or your spouse/common-law partner:
a.
An insider, director or senior officer (i.e. an officer or one of the five highest paid employees) of a publicly traded (exchange or over-the-counter) company or affiliate of such a company?
Or
Individually, or as part of a group, own more than 10% of the voting rights attached to all voting securities?
Yes
No
Company Name(s):
If yes, are you a Reporting Insider under Canadian securities legislation?
Yes
No
Company Name(s):
b.
Separately or in combination with other persons, a holder of more than 20% of the outstanding voting securities of a publicly traded (exchange or over-the-counter) company
or affiliate of such a company?
Yes
No
Company Name(s):
c. Individually, or as part of a group, a member with controlling interest in a publicly traded (exchange or over-the-counter) company or affiliate of such a company?
Yes
No
Company Name(s):
2. Do you have, or exercise authority over, any brokerage accounts with other financial institutions?
Yes Financial institution(s):
No Account Type:
3. Do you have, or exercise authority over, any accounts with BMO InvestorLine?
Yes
No Account #1:
Account #2:
INFORMATION ABOUT YOU (please
print clearly)
A
3. Other (please provide details)
If the country of your primary residence does not match with one of your tax residencies listed on this form, please either add the country of primary residence as a tax residence OR
in the section below provide an explanation for why you should not be considered as a tax resident in the country of your primary residence. A lack of a reasonable explanation may
cause your account to be reportable as a foreign resident account holder to the Canada Revenue Agency (CRA):
ABOUT YOUR BUSINESS
B
Reset Form
2
4. Will any other person have authority over, or any financial interest in, your account(s)? If another person will have authority over your account(s), please complete our “Authorized
Trading Agent or Power of Attorney” form
Yes
No Name:
5.
Will anyone other than yourself use or direct transactions in this account? This excludes those authorized to give instructions about the account, i.e., Joint Account Holder, Trading
Agent, Power of Attorney and Trustee.
Yes If yes, please complete the “Third Party Information”form. Please contact BMO InvestorLine for this form.
No
Please omit this section if the Applicant’s spouse or common-law partner is the Co-appIicant. Co-applicants must complete their own material change form if their information
has changed.
Last
First
Title
Name
Name
Employer
Occupation Name
Industry
Pro* BMO Staff
*You are considered to be a Pro if you, or someone you live with, is employed with an IIROC member firm or related company. Please provide a letter of confirmation from the member
firm’s Compliance department authorizing this account(s).
Please round to the nearest dollar.
Annual Income
from all sources
Net Liquid Assets (A)
(Cash & Securities less loans ________________________
outstanding against securities)
Net fixed Assets (B)
(Fixed assets less liabilities __________________________________
outstanding against fixed assets)
Estimated Net Worth (C)
(C=A+B)
Source of
Employment income
Student loans/bursaries or RESP
Unemployment benefits Social assistance Alimony (spousal support)
Annual Income
Retirement income Inheritance Real estate investment Investment in securities
Other
Intended use Short Term Investment Long Term Investment Income Generation
of the Account
Retirement Savings Education Savings Estate Planning
Savings
Other
_____________________________
I certify that the information on this form is true and complete; the information on this form shall supersede information previously provided; and the terms and conditions
of my Client Account Agreement remain in effect. In addition, I certify that I have disclosed all of my citizenships and residencies for tax purposes. I agree to advise you
immediately in writing of any material change in information.
Client __________________________________________________________________________________________________
Signature ________________________________________________________________________________________________________
Dat
e (YY/MM/DD)
SPOUSE or common-law partner information
FINANCIAL information
SIGNATURE
C
D
E
ABOUT YOUR BUSINESS (continued)
B
click to sign
signature
click to edit
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