TDA 371 F 09/18
Page 1 of 1
200 S 108th Ave
Omaha, NE 68154-2631
PO Box 2226
Omaha, NE 68103-2226
Fax: 800-914-8979
Please return this form to TD Ameritrade Clearing, Inc., by mail, fax, or as an attachment to a secure email sent from your TD Ameritrade account.
A $500 fee is assessed for each certificate delivered. An additional $500 fee may be charged for securities eligible but not participating in the
Direct Registration System (DRS). Please allow approximately four to six weeks for the Transfer Agent to generate and deliver the certificate.
Securities that are DRS eligible will be sent to the transfer agent. There is no fee for a DRS transfer out. A certificate request can be made to
the transfer agent once the transfer is completed. Please note, some stock issuers no longer provide certificates.
1. ACCOUNT INFORMATION
Account Number:
Number of Shares: Security:
Enter transfer agent account number if known:
2. RECIPIENT INFORMATION
Primary Owner/Trustee: Co-owner/Co-trustee:
U.S. Social Security or Tax
ID Number (TIN):
Date of Birth:
(MM-DD-YYYY)
U.S. Social Security or Tax ID
Number (TIN):
Date of Birth:
(MM-DD-YYYY)
Home Address:
(no PO box or mail drop)
City: State: ZIP Code:
Trust Name and Under Agreement Date (If Applicable):
3. IF THE RECIPIENT IS A MINOR, A CUSTODIAN MUST BE APPOINTED.
Full Legal Name:
Date of Birth:
(MM-DD-YYYY)
U.S. Social Security Number:
(SSN)
Home Address:
(no PO box or mail drop)
City: State: ZIP Code:
4. SHIP TO ADDRESS
Name:
Mailing Address:
City: State: ZIP Code:
5. AUTHORIZATION SIGNATURE(S)
✗
Account Owner’s Signature:
Date:
✗
Account Co-Owner’s Signature:
Date:
Only one signature is required from an owner of Joint Tenant or Tenant by Entirety accounts. All owners of other types of accounts are
required to sign.
Transfer Out - Direct Registration System
(DRS) and Certificate Request
*TDA371*
Investment Products: Not FDIC Insured * No Bank Guarantee * May Lose Value
TD Ameritrade, Inc. and TD Ameritrade Clearing, Inc., members FINRA/SIPC. TD Ameritrade is a trademark jointly owned by
TD Ameritrade IP Company, Inc. and The Toronto-Dominion Bank. © 2018 TD Ameritrade.
