F22V2 Copyright © 2019 Madison Trust Company Inc. All Rights Reserved.
madisontrust.com
Corporate Headquarters: 401 E. 8
th
St. Suite 200, Sioux Falls, SD 57103
A. ACCOUNTHOLDER INFORMATION
B. ADD AN AUTHORIZED REPRESENTATIVE OR INTERESTED PARTY TO MY ACCOUNT
What kind of party would you like to add to your account? (choose one)
Interested Party (default) – An Interested Party is authorized to access account informaion but is not authorized to provide direcions.
Account Representaive – An Account Representaive has full access to your account and is authorized to instruct Madison Trust concerning your account.
Account Representaive/Interested Party Contact Informaion
Name Email address
Firm/company name Phone number Fax number
Mailing address City State ZIP
Date of birth * Last 4 digits of Social Security Number *
Do you want the Account Representaive/Interested Party to be the Primary Contact for your account?
(The Primary Contact is contacted first should any quesions or concerns arise regarding your account.)
Yes – The above listed party is the Primary Contact for my account.
No – The above listed party is not the Primary Contact for my account.
C. REMOVE AN AUTHORIZED REPRESENTATIVE OR INTERESTED PARTY
D. ACKNOWLEDGMENT & SIGNATURE
Full name Account number
By signing below, I hereby authorize Madison Trust as Custodian, and their afiliates, to allow the aforemenioned Authorized Representaive or Interested Party to:
Access my account informaion, including copies of my account statements, tax filings and online account informaion.
Contact Madison Trust to discuss my account holdings and acivity.
I hereby acknowledge that any Authorized Representaive designated above may direct transacions on behalf of my account.
Accountholder signature Date
You must complete this authorizaion form to allow your Authorized Representaive or Interested Party to gain access to your account informaion.
Please complete and submit this form via one of the following methods:
Mail: Fax: Secure Upload: www.madisontrust.com/uploads
REPRESENTATIVE AUTHORIZATION
Please remove the following Authorized Representaive or Interested Party from my account:
