Fillable Participant Application and Designation of Beneciary (TD Ameritrade)

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Participant Application and Designation of Beneciary (TD Ameritrade)

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The Participant Application and Designation of Beneciary (TD Ameritrade) form is 17 pages long and contains:

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1
Questions? Call a New Accounts representative at 800-276-8746.
Please visit us at www.tdameritrade.com for more information about opening an account.
Return Options:
Electronically via Message Center:
Log in and go to Client Services >
Message Center to attach the le
Regular Mail:
PO Box 0, Omaha, NE 10-0
Overnight Mail:
00 South 10th Avenue
Omaha, NE 1-1
Fax: --
Participant Application
and Designation of
Beneciary
General Information
*TDA2705*
Type of plan:
Name of Employer/Plan Administrator:
Name of Company:
Employer Address:
City: State: Zip Code: Country:
Employer’s Federal Tax Identication Number:
Trustee Name:
Occupation:
Trustee U.S. Social Security Number:
Trustee Date of Birth:
Please see the important notice about qualied
pre-retirement survivor annuities in Section 8 of this form.
Is this account part of an existing plan at TD Ameritrade?
CC
Yes
CC
No
If yes, please provide an account number:
*If you have both pre-tax and Roth contributions to your plan, you will need to complete two Participant Application and Designation of
Beneciary forms.
Country of Citizenship:
CC
Check here if you are NOT a U.S. citizen.
CC
Money Purchase Pension Plan
CC
Individual 01(k)
CC
0(b)
CC
Prot-Sharing Plan
CC
Roth 01(k)*
Page 1 of 12 TDA 2705 A 03/21
Reset Form
* Nonresident aliens must submit a copy of a current passport and a copy of a bank or brokerage statement. If a U.S. address is listed,
then attach a Letter of Explanation for U.S. Mailing Address/Phone Number for Form W-. This form can be found on the
TD Ameritrade Forms Library: https://www.tdameritrade.com/form-library.
Non-U.S. citizens*: Do you hold a current U.S. immigration visa?
CC
Yes
CC
No
Specify visa type: Visa Number: Expiration:
Section 1, General Information continued
First Name of Participant: Middle Name: Last Name:
Mother’s Maiden Name:
Date of Birth:
Name Prex (optional):
CC
Mr.
CC
Mrs.
CC
Ms.
CC
Dr.
CC
Rev.
U.S. Social Security Number:
Number of Dependents:
Marital Status:
CC
Single
CC
Married
CC
Divorced
CC
Widow
Home Address (no PO box or mail drop):
Mailing Address: (if dierent from above)
City:
City:
State:
State:
Zip Code:
Zip Code:
Country:
Country:
Country of Citizenship:
Country of Birth:
CC
Check here if you are NOT a U.S. citizen.
Country of Dual/Secondary Citizenship (if applicable):
Non-U.S. citizens*: Do you hold a current U.S. immigration visa?
CC
Yes
CC
No
Specify visa type: Visa Number: Expiration:
*
Nonresident aliens must submit a copy of a current passport and a copy of a bank or brokerage statement. If a U.S. address is listed,
then attach a Letter of Explanation for U.S. Mailing Address/Phone Number for Form W-. This form can be found on the
TD Ameritrade Forms Library: https://www.tdameritrade.com/form-library.
Primary Phone number:
C C
Check here if this is not a U.S. phone number
Secondary Phone number:
C C
Check here if this is not a U.S. phone number
Participant Email (required for electronic delivery of your
account statement and trade conrmations):
Fax number:
CC
Check here if any Trustee, their spouse, any member of their immediate family living in the same household, including parents,
in-laws, siblings, and dependents is a member of the board of directors, 10% shareholder, or policy-making ocer of a publicly traded
company. Specify the name of the aliated person/Ocer, the company name, ticker symbol, address, city, and state:
Country of Birth:Country of Dual/Secondary Citizenship (if applicable):
Page 2 of 12 TDA 2705 A 03/21
CC
Check here if any Trustee, their spouse, any member of their immediate family living in the same household, including parents,
in-laws, siblings, and dependents is licensed, employed by or associated with a broker-dealer rm, a nancial services regulator,
securities exchange, or member of a securities exchange. If checked, please specify the name of the aliated person/Trustee
and aliated entity below. If this entity requires its approval for you to open this account, please provide a copy of the
required authorization letter (with this application):
CC
Check here if any Trustee, their spouse, any member of their immediate family, including parents, in-laws, siblings, and
dependents is, or is employed by, a federal or state registered Investment Advisor. Specify the name of the person aliated
with the Trustee employed by the Registered Investment Advisor and Investment Advisor company name:
CC
Check here if any Trustee, their spouse, any member of their immediate family, including parents, in-laws, siblings, and
dependents is using a license in a professional sale or trading capacity. Specify the name of the licensed professional,
their relationship to the trustee, and if associated with an entity:
Section 1, General Information continued
2
Authorized Agent Compensation
CC
Check here if any Authorized Agent (unaliated with the entity) is being compensated for providing investment advice, placing
trades, or otherwise managing the account.
Investment Objectives
Financial Information
Select the degree of risk you are willing to take with the assets in this account:
CC
Conservative
CC
Moderate
CC
Aggressive
CC
Speculative
Select the primary investment objective for this account:
CC
Conservation
CC
Moderate
CC
Moderate Growth
CC
Growth
CC
Aggressive Growth
Select the secondary investment objectives for this account: (Check at least one or all that apply)
CC
Conservation
CC
Moderate
CC
Moderate Growth
CC
Growth
CC
Aggressive Growth
CC
None
Select the liquidity needs for this account: (Check only one that applies)
CC
Within  months
CC
 -  months
CC
 -  months
CC
10 -  months
CC
More than 1 year
Select the investment time horizon for this account:
CC
Less than 1 year
CC
1 -  years
CC
 -  years
CC
 - years
CC
10-1 years
CC
1 years or more
3
Annual Income:
CC
0-1,
CC
1,000-,
C C
0,000-,
CC
100,000-,
CC
0,000-,
CC
00,000-,
CC
1,000,000-1,,
CC
,000,000+
CC
0-1,
CC
1,000-,
C C
0,000-,
CC
100,000-,
CC
0,000-,
CC
00,000-,
CC
1,000,000-1,,
CC
,000,000+
Approximate Liquid Net Worth: (cash, stocks, etc.)
4
Please
provide the
following
nancial
information.
For
denitions
regarding
investment
objectives,
please
see page
11 of the
application.
Approximate Net Worth: (not including residence)
CC
0-,
CC
,000-,
CC
0,000-,
CC
100,000-,
CC
0,000+
Page 3 of 12 TDA 2705 A 03/21
Cash Sweep Vehicle
My uninvested cash will be deposited in the TD Ameritrade FDIC Insured Deposit Account (IDA) as a part of the Cash
Balance programs. See the Client Agreement for a complete description of the Cash Sweep program. Other sweep choices
are available for clients with household values greater than 00,000 and cash balances of more than 100,000.
I understand my account statement will include sweep transactions involving bank deposits or money market funds in lieu
of immediate trade conrmations.
For those plans which require an alternative to the IDA due to regulation or applicable law, including certain 0(b) plan
accounts, the designated Sweep Vehicle will be the Federated Government Money Market Fund.
5
Trade Conrmations and Account Statements
I understand that I will receive monthly account statements and trade conrmations electronically, unless I make a selection below.
If I do not provide a valid email address, I will receive a quarterly paper statement or a monthly paper statement. Certain types of
accounts or activities (such as options trading) require a monthly statement, either electronically or via U.S. mail. I will be responsible
for any fees that apply. Accounts with a total liquidation value of 10,000 or an average of ve trades per month over a three-month
period are eligible to receive free paper statement and conrmation delivery.
Please note: If I elect to receive either electronic statements or electronic conrmations, I will receive shareholder information
electronically when available.
Account Statement:
CC
Electronic Monthly
CC
Paper Monthly ($2 fee may apply each month)
CC
Paper Quarterly ($2 fee may apply each quarter)
CC
Unless I have checked this box, TD Ameritrade is required to share my name and address with the companies I invest in through your
services so they may contact me directly about my investment. If I direct you not to share, you will receive the information on my
behalf and will forward it to me. Shareholder information includes proxy material, prospectuses, annual reports, and other corporate
communications. In some cases, regulations may require sharing information with the companies in which I have invested despite
this election.
Trade Conrmation:
CC
Electronic
CC
Paper
6
Send duplicate conrmations and statements to:
CC
My Employer
CC
Designated Party
Name:
Address:
You must designate at least one primary beneciary. If you select co-primary beneciaries, indicate the percentage of your account you
are designating to each. If a primary beneciary dies prior to the Participant, the remaining portion shall be payable proportionately
to any surviving primary beneciaries. You may also designate contingent beneciaries in the event that your primary beneciaries
do not outlive you. In the event that TD Ameritrade is unable to identify the beneciaries from the documents provided, the Custodial
Agreement will control.
State trust law may vary as to the legality of beneciaries naming subsequent beneciaries. Please consult a qualied tax advisor or
attorney regarding the applicable trust law for your state of residence.
If you are married and live in a state with community property statutes and do not designate your spouse as the sole beneciary, you
represent and warrant that your spouse has consented to such designation. Percentages must total 100% for all primary beneciaries
and 100% for all contingent beneciaries. If percentages are not indicated, they will be deemed equal shares. If percentages indicate
an attempt to distribute as equal shares, but do not add up to 100%, the rst named beneciary will receive a slightly higher percentage
(for instance, if you indicate %, .%, or .% for all three beneciaries, TD Ameritrade will round the rst beneciary’s percentage
up to .% and the other two beneciaries will each receive .%). Further, when securities cannot be evenly distributed, or there
are unclaimed securities, the Account Owner requests that such securities be liquidated and any proceeds from the liquidation be
distributed in the percentages requested to the named Beneciaries.
Subject to the condition(s) set forth in this section, I designate the following as the beneciary(ies) of my account:
Designation of Beneciary
7
City: State: Zip Code:
Page 4 of 12 TDA 2705 A 03/21
Section 7, Designation of Beneficiary continued
Designate your Primary Beneciary(ies)
Primary Share %:
CC
Per StirpesBeneciary is:
CC
An individual
CC
A trust
CC
Other (custodianship, charity, corporation, etc.)
Beneciary's Name:
Relationship:
Primary Share %:
CC
Per StirpesBeneciary is:
CC
An individual
CC
A trust
CC
Other (custodianship, charity, corporation, etc.)
Beneciary's Name:
Relationship:
Primary Share %:
CC
Per StirpesBeneciary is:
CC
An individual
CC
A trust
CC
Other (custodianship, charity, corporation, etc.)
Beneciary's Name:
Relationship:
Total: % Total must add up to 100%
Primary Share %:
CC
Per StirpesBeneciary is:
CC
An individual
CC
A trust
CC
Other (custodianship, charity, corporation, etc.)
Beneciary's Name:
Relationship:
Primary Share %:
CC
Per StirpesBeneciary is:
CC
An individual
CC
A trust
CC
Other (custodianship, charity, corporation, etc.)
Beneciary's Name:
Relationship:
SSN/TIN:
Date of Birth/UA Date/Date of Formation:
SSN/TIN:
Date of Birth/UA Date/Date of Formation:
SSN/TIN:
Date of Birth/UA Date/Date of Formation:
SSN/TIN:
Date of Birth/UA Date/Date of Formation:
SSN/TIN:
Date of Birth/UA Date/Date of Formation:
OR
OR
OR
OR
OR
Page 5 of 12 TDA 2705 A 03/21
0
Section 7, Designation of Beneficiary continued
Designate your Contingent Beneciary(ies)
Contingent Share %:
CC
Per StirpesBeneciary is:
CC
An individual
CC
A trust
CC
Other (custodianship, charity, corporation, etc.)
Beneciary's Name:
Relationship:
Contingent Share %:
CC
Per StirpesBeneciary is:
CC
An individual
CC
A trust
CC
Other (custodianship, charity, corporation, etc.)
Beneciary's Name:
Relationship:
Contingent Share %:
CC
Per StirpesBeneciary is:
CC
An individual
CC
A trust
CC
Other (custodianship, charity, corporation, etc.)
Beneciary's Name:
Relationship:
Total: % Total must add up to 100%
Contingent Share %:
CC
Per StirpesBeneciary is:
CC
An individual
CC
A trust
CC
Other (custodianship, charity, corporation, etc.)
Beneciary's Name:
Relationship:
Contingent Share %:
CC
Per StirpesBeneciary is:
CC
An individual
CC
A trust
CC
Other (custodianship, charity, corporation, etc.)
Beneciary's Name:
Relationship:
SSN/TIN:
Date of Birth/UA Date/Date of Formation:
SSN/TIN:
Date of Birth/UA Date/Date of Formation:
SSN/TIN:
Date of Birth/UA Date/Date of Formation:
SSN/TIN:
Date of Birth/UA Date/Date of Formation:
SSN/TIN:
Date of Birth/UA Date/Date of Formation:
OR
OR
OR
OR
OR
Page 6 of 12 TDA 2705 A 03/21
✔
0
Spousal Consent for Qualied Retirement Plans (01k, PSP, MPPP, 0b plans
that use TD Ameritrade's adoption agreement)
(Only required if spouse is not named 100% primary beneciary in Section 7.)
I, the undersigned spouse of the Participant, hereby certify that I have read this Participant Application and Designation of Beneciary
and fully understand that the property subject to the designation is my spouse's accrued benet under the Plan, in which I possess a
benecial interest, provided I survive my spouse. Being fully satised with the provisions of the designation, I hereby consent to and
accept the above beneciary designation, without regard to whether I survive or predecease my spouse. This consent is irrevocable
unless my spouse changes the beneciary designation or designates me to receive 100% of the accrued benet.
STOP HERE PLEASE! This document must be signed in the presence of a Notary Public ONLY if your spouse is not named 100%
beneciary in Section .
X
Spouse's Printed Name:
(Notary Public use only)
County of: )
) ss
State of: )
Subscribed to and sworn to before me this
day of .
Notary Public:
[SEAL]
Section 7, Designation of Beneficiary continued
8
Instructions for Waiver Election for Qualied Pre-Retirement Survivor Annuities
About Qualied Pre-Retirement Survivor Annuities
If you are a married participant in your employer’s qualied retirement plan, the law requires that any amount remaining in your plan
account be paid to your surviving spouse in a certain manner at your death. This manner of payment, called a “Qualied Pre-Retirement
Survivor Annuity,” will provide your spouse with a series of periodic payments over his or her life. The size of the periodic payments will
depend on the amount remaining in your plan account.
For example, assume that a participant dies with an account balance of 10,000. If the balance is paid to the surviving spouse in the form
of a Qualied Pre-Retirement Survivor Annuity, the annuity will provide the spouse with monthly payments of .0. (This payment
amount is an estimate based on the Individual Annuity Mortality Tables - 1 using a % interest rate with payments commencing at
age .)
You may elect to waive the following:
. The requirement that your surviving spouse be paid in the form of a Qualied Pre-Retirement Survivor Annuity; and
. The requirement that your spouse be your beneciary (only if applicable).
You may make either or both of the above elections beginning with the rst day after which you become a participant in the plan. Any
waiver election you sign before age  will become invalid the rst day of the plan year in which you attain age . At that time you may
again waive the Qualied Pre-Retirement Survivor Annuity and the requirement that your spouse be your beneciary.
Sign Here
Spouse's Signature:
Date:
Page 7 of 12 TDA 2705 A 03/21
Important Information
9
Your spouse must consent in writing to either waiver. You have the right to revoke any waiver that you have made at any time
before your death. Your spouse must also consent to any subsequent changes of beneciary.
If your vested account balance is ,000 or less at the time of your death, the plan administrator may make a distribution to your
surviving spouse in a single sum cash payment even if you did not waive the Qualied Pre-Retirement Survivor Annuity.
Because a spouse has certain rights under the law, you should inform your plan administrator immediately of any changes in your
marital status. A change in your marital status may require you to complete a new Participant Application and Designation of
Beneciary form.
For more information regarding Qualied Pre-Retirement Survivor Annuities, contact your plan administrator (employer).
Trusted Contact (Optional)
By completing this section, you authorize TD Ameritrade to contact the person(s) named below for the following reasons: if there are
questions or concerns about my whereabouts or health status; if TD Ameritrade suspects that I may be a victim of fraud or nancial
exploitation; if TD Ameritrade suspects that I might no longer be able to handle my nancial aairs; to conrm the identity of any legal
guardian, executor, trustee, authorized trader, or holder of a power of attorney; or if TD Ameritrade has any other concerns or is unable
to contact me about my account(s) held at TD Ameritrade. Please review the Client Agreement for the full terms and conditions
regarding how TD Ameritrade uses this information.
NOTE: Your Trusted Contact must be someone other than an account owner. You may provide more than two Trusted Contact
Persons by completing and signing additional Authorization Forms.
Relationship:
First Name: Middle Initial: Last Name:
Phone number: Email:
City: State: Zip Code: Country:
Mailing Address:
10
Relationship:
First Name: Middle Initial: Last Name:
Phone number: Email:
City: State: Zip Code: Country:
Mailing Address:
Page 8 of 12 TDA 2705 A 03/21
X
X
X
Participant's Signature:
Participant's Spouse's Signature: (Must be witnessed. See below)
Notary Public/Signature Guarantee:
Date:
Date:
Date:
Sign Here
11
Waiver Election (For Qualied Pre-Retirement Survivor Annuity)
CC
The Plan Administrator will check here if the following election does NOT apply.
Married Participant’s Election to Waive the Qualied Pre-Retirement Survivor Annuity
As a married participant in my employer’s qualied retirement plan, I acknowledge that I have read the information about Qualied
Pre-Retirement Survivor Annuities below. I understand that when I die, any amount remaining in my plan account will be paid to my
surviving spouse in the form of a Pre-Retirement Survivor Annuity. I understand that I have a right to waive that form of payment.
I hereby elect to waive the requirement that my surviving spouse be paid any benets that I may have in the plan at the time of my
death in the form of a Qualied Pre-Retirement Survivor Annuity. I understand and agree that this waiver is valid only if my spouse has
consented by reading and signing the statement below.
I am the spouse of the participant named above. I hereby consent to my spouse’s election not to have benets
remaining in his or her plan paid in the form of a Qualied Pre-Retirement Survivor Annuity at his or her death.
I understand that my consent cannot be revoked unless my spouse revokes the above waiver.
Witness of Spouse’s Consent The signature of the spouse must be witnessed by a notary public or signature
guarantee as required. (Witness applies to either or both elections.)
Notary Public
EMPLOYEE: You and your spouse must complete the Waiver Election section if the box above has not been checked.
EMPLOYER: The Waiver Election is applicable to all Money Purchase Pension Plans, Dened Benet Pension Plans, and Target Benet
Plans. It also applies to Prot-Sharing Plans and 01(k) Plans if you did not select the REA Safe Harbor found in the Adoption Agreement.
If you did select the REA Safe Harbor provision and no existing plan assets are subject to the REA annuity requirements, place a check
mark in the indicated box above.
(Notary Public use only)
County of: )
) ss
State of: )
Subscribed to and sworn to before me this
day of .
Notary Public:
[SEAL]
Page 9 of 12 TDA 2705 A 03/21
12
ERISA Information
Plan Information - Fiduciary
If You Are Using a Third-Party Administrator or Record Keeper,
Please Provide the Following Information:
CC
Check here if the plan will NOT be covered under ERISA. Please ensure that the ERISA question within Section 7 of the
Adoption Agreement lists “No.”
CC
Check here if the plan is covered under ERISA, and complete the information below.
Fiduciary's Address:
TPA/Record Keeper Address:
Plan Fiduciary First Name:
TPA/Record Keeper Name:
Middle Name: Last Name:
Contact Name:
Fiduciary's Phone number:
TPA/Record Keeper Phone number:
Fiduciary's Email:
TPA/Record Keeper Email:
City:
City:
State:
State:
Zip Code:
Zip Code:
Page 10 of 12 TDA 2705 A 03/21
TD Ameritrade, Inc. and TD Ameritrade Clearing, Inc., members FINRA/SIPC, are subsidiaries of The Charles Schwab Corporation.
TD Ameritrade is a trademark jointly owned by TD Ameritrade IP Company, Inc. and The Toronto-Dominion Bank.
©01 Charles Schwab & Co. Inc. All rights reserved.
Account Agreement
I have received and read the Client Agreement, which is incorporated by this reference, that will govern my account. I agree to be bound
by this Client Agreement, as amended from time to time, and request an account to be opened in the name(s) set forth below. All
securities, dividends, and proceeds will be held at TD Ameritrade Clearing, Inc., unless otherwise instructed. I understand that
TD Ameritrade may obtain a current consumer or credit report to determine my eligibility, or continuing eligibility, for credit or for other
legitimate business purposes. Any decision by TD Ameritrade to extend credit may be based on information contained in a consumer
or credit report, as well as the policies of TD Ameritrade and TD Ameritrade Clearing, Inc. I understand that TD Ameritrade may relate
information regarding this account, including account delinquency and voluntary closures, to consumer or credit reporting agencies.
Upon my request, TD Ameritrade shall inform me of each consumer or credit reporting agency from which they have obtained and/
or reported my consumer or credit report. TD Ameritrade agrees to notify the consumer or credit reporting agencies if I dispute the
completeness or accuracy of the information furnished by TD Ameritrade. By my signature below, I authorize TD Ameritrade to obtain
consumer or credit reports for the name(s) set forth below. I understand that non deposit investments purchased through
TD Ameritrade are not insured by the FDIC, are not obligations of or guaranteed by any nancial institution, and are subject to
investment risk and loss that may exceed the principal invested.
The undersigned hereby acknowledges that he/she has received and read the TD Ameritrade, Inc. and TD Ameritrade Clearing, Inc.
Section 0(b) () Disclosure Summary document.
Important information about procedures for opening a new account:
To help the government ght the funding of terrorism and money laundering activities, federal law requires all nancial
institutions to obtain, verify, and record information that identies each person who opens an account.
What this means for you: When you open an account, we will ask for your name, address, date of birth, and other information that
will allow us to identify you. We may also utilize a third-party information provider for verication purposes and/or ask for a copy
of your driver’s license or other identifying documents. By my signature below, I attest that I am of legal age to contract, and I
certify, to the best of my knowledge that the information provided on this application is complete and correct.
If I am a U.S. person for tax purposes:
Under penalties of perjury, I certify that: (1) the number shown on this form is my correct taxpayer identication number; () I
am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notied by the
Internal Revenue Services (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends,
or (c) the IRS has notied me that I am no longer subject to backup withholding; () I am a U.S. citizen or other U.S. person; and
() the FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
If I have been notied by the IRS that I am subject to backup withholding because I have failed to report all interest and dividends
on my tax return, I must cross out () in this certication.
If I am not a U.S. Person for tax purposes:
I am submitting the applicable Form W- with this form to certify my foreign status.
The IRS does not require your consent
to any provision of this document
other than the certications required
to avoid backup withholding.
The Client Agreement applicable to this brokerage account contains a predispute
arbitration clause. By signing this agreement, the parties agree to be bound by the terms
of the Client Agreement, including the arbitration agreement located in Section 12 of the
Client Agreement on page .
X
X
Participant's Signature: Employer's Signature:
Date: Date:
Sign Here
Original
signatures
are required;
electronic
signatures
and/or
signature
fonts are not
authorized
13
Investment Products: Not FDIC Insured * No Bank Guarantee * May Lose Value
Page 11 of 12 TDA 2705 A 03/21
Investment Objectives Denitions
Conservation: Reects your desire to seek very low risk and minimize potential loss of principal. You may seek income from your
investments while understanding that returns may not keep pace with ination. You may also intend to invest over a short period of time.
Moderate: Reects your desire to seek lower risk and uctuation in your portfolio, while striving to achieve more stable returns on your
investments. It may also mean that you plan to invest over a short period of time.
Moderate growth: Reects your desire to seek growth in your portfolio by typically using a balance of growth and conservative
investment types. It may also mean that you are moderately tolerant of risk and plan to invest for a medium to long period of time.
Growth: Reects your desire to seek the potential for investment growth, as well as your tolerance for more signicant market
uctuations and risk of loss. It may also mean that you plan to invest over a long period of time.
Aggressive Growth: Reects your desire for potentially substantial investment growth, as well as your tolerance for large market
uctuations and increased risk of loss. It may also mean that you plan to invest over a long period of time.
Page 12 of 12 TDA 2705 A 03/21
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Participant Application and Designation of Beneciary (TD Ameritrade)

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Completed 26 March 2021

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