Page 1 of 1 817-03-109E (12/06/2017)
5. Signatures and Authorization
The undersigned hereby authorizes the execution of the above.
I conrm that I am duly licensed to distribute the product the Borrower
wishes to purchase in the jurisdiction where the Borrower resides
4. Special Instructions/Additional Information
3. Redemption Instructions
Segregated Fund Company
Wire Order Number
Pay Out Loan ICS (advisor) Mail (client) EFT (Account on le) or
EFT (VOID cheque attached)
$ Amount or % or Unit
(Redemption is the sale of a security)
Segregated Funds Redemption Form
Dealer Number Dealer Name
1. Dealer/Advisor Information
2. Client Information
Joint Account Holder Last Name (If applicable)
Advisor Name (Last, First, Initial)
B2B Bank Pledged Account Number:
Last Name First Name
Copy by Fax
Original by Mail / Courier
ONLY one method required
Pages : of
Fax to: 416.941.7714 or 1.866.941.7711
199 Bay Street, Suite 600
PO Box 279 STN Commerce Court
Toronto ON M5L 0A2
Dealer x-reference number:
INSTRUCTIONS ON HOW TO COMPLETE THIS FORM
METHOD OF TRANSMISSION
Indicate whether this form is being submitted by fax or if the original form is
being mailed or couriered to B2B Bank. Please note that B2B Bank is not
responsible for duplicate transactions if the request is sent more than once.
Provide information regarding the B2B Bank Pledged account number.
Indicate how many pages of instructions are being transmitted to B2B Bank
(ex: Pages 1 of 2).
Provide the Dealer and Advisor’s name and code numbers.
Provide the information requested regarding the client’s name.
Use this section to indicate the mutual fund code (mandatory), the segregated
fund company account number and the redemption amount. Also indicate
whether the amount is a “Gross”, “Net” amount. Client(s) signature(s) is/are
required for withdrawal requests. The signature(s) must be guaranteed by a
Dealer or a Bank.
The “Special Instruction” section is used to inform B2B Bank of any special
processing information relating to the requested change.
In addition to the date, the Client’s and Advisor’s signature is required on
this form. The Dealer and Advisor numbers are required to ensure that
commission and service fees are credited correctly, where applicable.
Please complete additional Segregated Funds Redemption Forms if there are
more than ve (5) transactions per client. Please indicate the client’s name
and account number on each form along with the total number of instruction