DOC0114F120 Amerprse Fnancal Servces, Inc. 70100 Amerprse Fnancal Center Mnneapols, MN 55474 Change of Ownershp/Annutant For Brokerage platform products, you must frst create the applcable product account va eforms New Busness n the approprate ownershp and submt the sgned summary applcaton. Brokerage account ownershp changes requre an account frst be establshed n the desred ownershp and lsted n Part 4. Full account ownershp transfers wll nactvate arrangements and features on the orgnal account ncludng, but not lmted to: check wrtng, systematc payouts, bank authorzatons, dvdend methods, etc. All non-bllng/restrcted Amerprse Managed Accounts are establshed wthout an nterest bearng money settlement opton. To establsh an nterest bearng money settlement opton, please work wth your Amerprse Advsor to complete the approprate Amerprse Managed Accounts applcaton. Ths form may not be used for Qualfed Accounts, except n lmted stuatons. For all annutes lnked to a brokerage or SPS account, before proceedng, ensure the brokerage or SPS account the annuty s to be lnked wth s of the exact same ownershp. Ownershp changes on RverSource annutes ssued n Calforna wth the Enhanced Legacy SM beneft requre the acknowledgment to be ntaled n Part 5. Clent ID 001 Part 1 Current Account Owner(s) Complete Sutablty Informaton n Part 6 for each new account. Account Number (s) 1. 2. Account Number Admn Code Account Number Admn Code Owner or Fducary Name Trust or Entty Name Jont Owner Name Jont Owner Clent ID 001 Part 2 Gftng/Value Receved Informaton 1. Is the Change of Ownershp due to a dvorce? Yes 2. Product (Select all that apply): Lfe Insurance polces and Annuty contract (2A) No Brokerage and Managed Accounts (2B) Mutual Fund/Certfcates (2B) Sgn on page(s) 3, 4 and 14 Fax # 1.866.478.8767 2008-2015 Amerprse Fnancal, Inc. All rghts reserved. F120 Page 1 of 14
DOC0214F120 2A. Lfe Insurance polces and Annuty contracts only Questons 1 and 2 below are vald for Lfe Insurance polces or Annuty contracts ONLY. 1. Is ths a transfer to a spouse, owner's revocable trust, owner's lvng trust, spouse's revocable trust, or spouse's lvng trust? Yes No 2. You hereby absolutely and uncondtonally sell, transfer and convey. If no opton s selected, the default s gft Wth the ntenton of makng a gft For full value receved If gftng s selected, or defaulted to, a 1099 may be ssued. Generally transfer of annuty ownershp, whether by gft or for value receved, s a taxable event. Please consult your tax advser. 2B. Brokerage, Mutual Funds and Managed Accounts (All questons must be completed) Questons 1-4 below are vald for Brokerage, Mutual Funds and Managed Accounts ONLY. 1. Is ths transfer a Gft? If no opton s selected, the default s gft Yes No - f 'No', select one of the followng optons Sale for Full Value Receved Other 2. Is any recpent of the transfer a: Spouse Trust Ex-Spouse Other 3. Is ths transfer wthn 1 year of date of dvorce OR pursuant to dvorce decree? Yes No 4. If any current owner OR any recpent s a trust, s the trust a: Revocable Trust wth one Grantor wth two Grantors who are spouses wth multple Grantors (Please specfy) (Please specfy) Irrevocable Trust Irrevocable Trust treated as Grantor Trust Part 3 Transfer Amount and Authorzaton Thrd Party Annuty or Insurance (Except RverSource RAVA 5 ) Ths form cannot be used to change the ownershp, request dvorce settlement, or enable hold restrctons for annuty contracts and/or nsurance polces lnked to the ndcated brokerage account number. Amerprse Fnancal, Inc. cannot process the ownershp change for annutes or nsurance products held at a thrd party carrer. Please contact the carrer drectly to obtan the requred paperwork and to facltate the desred ownershp change. Reman lnked to the exstng Amerprse brokerage account. The currently lnked Amerprse brokerage account ownershp no longer matches the thrd party annuty/nsurance contract ownershp, lnk all assocated annuty/nsurance contracts to the followng account : 133 For Columba Mutual Funds (not held n a brokerage account) Full OR Partal (complete only one): $ OR % OR Shares F120 Page 2 of 14
DOC0314F120 For Brokerage, SPS Advantage and Actve Portfolos accounts: Please ndcate the amount of cash or securtes to be transferred. If no amount s specfed, we wll transfer 100%. If you are requestng a cash amount, there must be suffcent cash n the sweep account to cover the amount requested. If your default lot relef method s average, we are unable to process a request for specfc tax lots. Transfer all Cash and Securtes Transfer all Securtes Only Transfer Partal Cash Amount $ Transfer all Cash Only Transfer Percentage of Entre Account: % Transfer Partal Securtes Only Transfer the ndvdual securtes dentfed n the table below. Complete the table to provde nstructons for the transfer of ndvdual securtes held n your account. If there s nsuffcent room to lst all securtes below, you may attach a lst sgned and dated by the current owner and enter see attached lst n ths part. CUSIP Securty Descrpton Securty Type (Stock/Bond/MF) Purchase Date MM/DD/YYYY Prce Quantty Total Cost CUSIP Securty Descrpton Securty Type (Stock/Bond/MF) Purchase Date MM/DD/YYYY Prce Quantty Total Cost For All Change of Ownershp Requests: Amerprse Fnancal s not responsble for the suffcency or valdty of ths transfer of ownershp. If ths polcy/contract/account has been assgned as collateral, ths transfer of ownershp s made subject to that assgnment. For Annutes and Lfe Insurance: Subject to the approval of RverSource Lfe Insurance Company, you absolutely and uncondtonally transfer ownershp of the above descrbed lfe nsurance polcy/annuty contract to the person(s) named n Part 5 A, B, C or D and hs/her successors or assgns. If any contngent owner has been named n ths polcy/contract, or by subsequent nstrument, that desgnaton of contngent owner s hereby revoked. The current benefcary desgnaton wll reman n effect unless changed by the new owner(s). For Mutual Funds, Certfcate and Brokerage Accounts: Subject to the approval of the fund or Amerprse Certfcate Company, you absolutely and uncondtonally transfer ownershp of the above descrbed lfe mutual fund, certfcate or brokerage account to the person(s) named n Part 5 A, B, C or D. The transfer of ownershp hereby revokes any trust or TOD desgnaton prevously created wth respect to sad shares or certfcate to the extent of the funds beng assgned hereby. You rrevocably appont Amerprse Fnancal Servces, Inc. as your attorney to transfer sad securtes on the books of the ssuer, wth full power of substtuton n the premses. REIT/BDC holdngs: Please note; f an account or poston s transferred to a new owner, or n the event that an owner s removed from the exstng account, the owner s Dstrbuton Renvestment Plan (DRIP) electon wll be changed to cash. To change the dstrbuton electon, submt form F246 "Change Dstrbuton Electon for Real Estate Investment Trusts (REIT) Investment or Busness Development Companes (BDC)" along wth the transacton request. If there s an Alternatve nvestment n a Qualfed Plan, addtonal paperwork may be requred to move or re-regster the assets. All owners and fducares dentfed n Part 1 must sgn below: X X Date Sgned MM/DD/YYYY MM/DD/YYYY F120 Page 3 of 14
DOC0414F120 For UGMA/UTMA Any request for an ownershp change of an account regstered under UTMA/UGMA to an owner other than the former mnor orgnally named on the account wll requre that the mnor, who has now reached age of majorty, must sgn above and have ther sgnature notarzed below. On ths day of, A.D. (year), before me, a Notary Publc n and for sad County and State, resdng theren, duly commssoned and sworn, personally appeared, known to me to be the person whose name s subscrbed to the wrtten nstrument, and acknowledged to me that he or she executed the same as hs or her free act and deed. In Wtness Whereof, I have hereunto set my hand and affxed my offcal seal ths day and year n ths certfcate frst above wrtten. Notary Publc n and for sad County and State X F120 Page 4 of 14
DOC0514F120 Part 4 Transfer to Another Exstng Account Held n the Requested Ownershp For Columba mutual funds (not held n a brokerage account) that are to be transferred to an exstng Columba mutual fund account of the same type, please lst the recevng account numbers below. New account numbers wll be created for ths type of transfer f they are requred. Account Number Account Number Account Number For Brokerage, Amerprse ONE fnancal accounts and Amerprse Managed Accounts that are to be transferred to exstng Brokerage, Amerprse ONE fnancal accounts and Amerprse Managed Accounts of the same type, please lst the recevng account numbers below. Account Number Account Number Account Number Any change n the account ownershp wll requre a new account number to be establshed. If an account does not currently exst n the desred ownershp, your Amerprse Fnancal Advsor must create an account for the requested ownershp and provde the account number (s) below to avod any processng delays. If the source account s an Amerprse Brokerage account and you do not have an Amerprse Advsor, please contact 1-800-862-7919 to request the applcable new busness applcaton. For SPS Advantage and Actve Portfolos accounts only: Check ths box f the new owner wll be termnatng the account(s) wthn 90 days. We wll establsh a restrcted Amerprse Managed Account. (Ths opton apples only to Amerprse Managed Accounts that fall below the mnmum asset threshold or to clents wthout an Amerprse Advsor). All non-bllng/restrcted Amerprse Managed Accounts are establshed wthout an nterest bearng money settlement opton. To establsh an nterest bearng money settlement opton, please work wth your Amerprse Advsor to complete the approprate Amerprse Managed accounts applcaton. New Owner Electons (SPS Advantage or Actve Portfolo accounts only): Check the box besde the opton elected. If no opton s elected, we wll assume that the new owner's ntenton s to lqudate the account wthn 90 days of completon of the ownershp change. New Owner wll be termnatng the exstng Managed Accounts agreement(s) after re-regstraton and agrees to the followng terms; No account management fee wll be charged No SPS Advantage account Servces wll be provded Account actvty wll be lmted to full lqudatons and n-knd transfers only The new owner s responsble for full lqudaton or n-knd transfer of the account wthn 90 days of completon of the Change of Ownershp/Annutant form and may call 1.800.862.7919 for further nstructons. If the account s not lqudated wthn 90 days after completng the Change of Ownershp, we wll transfer the account assets nto an Amerprse Brokerage account n the same ownershp. All applcable brokerage fees as descrbed n the Amerprse Brokerage Clent Agreement and Other Important Dsclosures document wll apply to the account. Margn Account Agreement - SPS Advantage accounts only Complete ths secton f the orgnal source account s authorzed for margn and currently carres margn debt. If you do not elect to have a margn account by checkng the box below, no margn account wll be provded. Yes, you agree to have a margn account* Indcate your expected use of the margn account (select at least one opton. If nether expected use box s checked, Amerprse assumes the clent wll use margn to leverage equty). Use margn to Leverage Equty. Ths account wll leverage current portfolo to purchase addtonal securtes. Use margn to Mantan Lqudty. Ths account wll leverage current portfolo to provde lqudty/cash flow. (Margn s not allowable on all types of ownershps. Please consult wth your advsor as to whether margn s avalable for ths ownershp.) * By checkng ths box you agree that you have receved the Amerprse Strategc Portfolo Servce Advantage Clent Agreement and are bound by the terms set forth n the margn agreement theren. Part 5 New Account Regstraton (Select One) State of Resdence F120 Page 5 of 14
DOC0614F120 Owners of Brokerage, SPS Advantage, Actve Portfolos nvestments, and Amerprse ONE Fnancal Accounts must also complete Part 7 of ths form. Please contact our offce at 1.800.862.7919 f the ownershp regstraton you need s not lsted. To desgnate an Attorney-In-Fact, a completed Amerprse Power of Attorney form (402540) s requred. If the new account regstraton s for an IRA, the choce below must be Indvdual, or f the IRA owner s a mnor/protected person, UGMA/UTMA. If you own a varable annuty wth the Guarantor Wthdrawal Beneft for Lfe (GWB for Lfe ) or SecureSource rder sngle lfe beneft, transfer of ownershp may result n a reset of the Annual Lfetme Payment (ALP). If the ALP wll decrease, the Beneft Impact Acknowledgement form wll be requred before processng wll occur. If requred, ths form wll be maled to you or you may contact our offce for assstance. For all other wthdrawal benefts wth the sngle lfe beneft, f the covered person changes as a result of the ownershp change, the rder termnates. If you own a varable annuty wth the SecureSource, SecureSource Flex, SecureSource Stages, or SecureSource Stages 2 jont lfe beneft, transfer of ownershp to anyone other than the covered spouses or ther revocable trust s not allowed. If you own a varable annuty wth the SecureSource 3, SecureSource 4 SM or SecureSource 4 Plus SM jont lfe beneft, transfer of ownershp to anyone other than the covered spouses or ther revocable trust wll termnate the rder. For contracts ssued n Calforna, f you own a varable annuty wth the SecureSource 3, SecureSource 4 SM or SecureSource 4 Plus SM sngle lfe beneft, the covered person (for jont, covered spouses) wll not change and the rder wll not termnate as a result of an ownershp change. For sngle lfe beneft, the rder wll termnate at the death of the covered person or any owner (even f the covered person s stll lvng). For jont lfe beneft, the rder wll termnate at the death of the last covered spouse or any owner (unless spousal contnuaton s chosen by a covered spouse). For contracts ssued n Florda wth the SecureSource 3 jont lfe beneft, transfer of ownershp to anyone other than the covered spouses or ther revocable trust s not allowed. For all other wthdrawal beneft rders, Florda contracts follow the rules stated above. If you own a varable Annuty wth a death beneft rder, transfer of ownershp may termnate the rder or reset the death beneft guaranteed amount. Jont owners and/or jont annutants are not allowed on a varable Annuty wth the Enhanced Legacy SM beneft. Acknowledgment for annuty contracts ssued n Calforna wth the Enhanced Legacy SM beneft (ELB) An ownershp change wll result n an owner and annutant that are no longer the same person. The benefts provded under the Enhanced Legacy beneft are only payable at the annutant's death. You must acknowledge by ntalng below that you understand: If the owner des before the annutant, the Standard Death Beneft value wll be pad to the benefcary(es). If the annutant des before the owner, the Enhanced Legacy beneft value wll be pad to the benefcary(es). The annutant cannot be changed. Intals of current owner Intals of new owner Choose Regstraton (Select one) Indvdual (Complete 5A and f approprate 5E) Jont Tenants wth Rghts of Survvorshp (WROS) (Complete 5A and 5B) - For annutes, rghts of survvorshp are only avalable f the jont owners are husband and wfe. In all other cases of annuty jont ownershp, owners are tenants n common. For Lousana state resdents: Jont Tenants wth Rghts of Survvorshp (WROS) regstraton s not avalable. Guardan/Conservator/Next Frend (Complete 5A and 5D) - If a fducary ownershp such as Guardanshp or Conservatorshp s chosen, a court-certfed copy of the court order appontng the fducary and an Amerprse Fducary Informaton Form (402541) are requred. UGMA/UTMA/CESA (Complete 5D and 5E) - If UTMA ownershp s selected for a Mnor/Protected Person owner, Socal Securty Number for the Mnor/Protected Person must be ncluded. Communty Property (Complete 5A and 5B) - Communty Property ownershp regstraton for annuty contracts s always establshed wth rghts of survvorshp. For all other types of accounts Communty Property ownershp regstraton s establshed wthout rghts of survvorshp unless otherwse ndcated. Trust (Complete 5C) - Complete and submt the requred Amerprse Certfcate of Trust form (131202). The Taxpayer Identfcaton Number (TIN) for the Trust as well as the names of all trustees and the date of the trust must be ncluded (Amerprse Fnancal Servces, Inc. wll not permt contnued use of a decedent's personal TIN for accounts regstered n Trust ownershp). Organzaton (Complete 5C) - Complete and submt the requred Amerprse Corporate Resoluton form (402400) dentfyng those offcers authorzed to sgn on behalf of the organzaton must be ncluded along wth a copy of a government-ssued busness lcense or a copy of the Artcles of Incorporaton for the organzaton. Tenants by Entrety (Complete 5A and 5B) - For Lousana state resdents: Tenants by Entrety regstraton s not avalable. Tenants n Common (Complete 5A and 5B) Change Annutant (Complete 5F) F120 Page 6 of 14
DOC0714F120 New Regstraton Informaton (for all types of accounts) Select one: Change TIN Change Owner We are requred by law to obtan certan personal nformaton from you whch wll be used by us to verfy your dentty. If you do not provde us the nformaton, we may not be able to open your account. If we are unable to verfy your dentty we reserve the rght to close your account or take other such steps as we deem reasonable. Is ths account for a clent that s a bank, savngs and loan assocaton, nsurance company, regstered nvestment company or nvestment advsory frm? Yes No Do the total assets owned by the clent(s) exceed $50MM? Yes No Note: f no electons are made to the above queston, we wll assume that the answers to both the questons s "no". 5A - Indvdual Owner Name as t appears n IRS Records Socal Securty Number Relatonshp to Current Owners n Part 2 Date of Brth (MMDDYYYY) Ctzenshp (Select One): U.S. Ctzen Resdent Alen Non-Resdent Alen Gender: Male Female Martal Status (Select One): Marred Dvorced Sngle Resdental Address: Please check here f ths s an address change. For alternate address requests, please submt Form 518. Cty State ZIP code 5B - Jont Owner wth Indvdual Owner n Part 5A Name as t appears n IRS Records Socal Securty Number Relatonshp to New Owner n Part 5A Date of Brth (MMDDYYYY) Ctzenshp (Select One): U.S. Ctzen Resdent Alen Non-Resdent Alen Gender: Male Female Martal Status (Select One): Marred Dvorced Sngle Resdental Address: Please check here f ths s an address change. For alternate address requests, please submt Form 518. Cty State ZIP code 5C - Trust or Organzaton If a Trust s to be regstered as an owner of an account that ncludes Amerprse ONE Fnancal Account features, each trustee must submt a clent profle pror to establshng a new account. A clent profle form must be submtted for trusts and organzatons that are new clents before the change of ownershp can be processed. Trustee or Offcer of Organzaton Name(s) Date of Trust (MMDDYYYY) Trustee or Offcer of Organzaton Name(s) F120 Page 7 of 14
DOC0814F120 Trust or Organzaton Name TIN If Trust s new owner (Select One): Revocable Irrevocable Busness Address: Please check here f ths s an address change. For alternate address requests, please submt Form 518. Cty State ZIP code 5D - UTMA/UGMA for Mnor or Fducary for Mnor/Protected Person or Protected Person, CESA Change of Benefcary or Controller UTMA UGMA CESA Fducary Fducary, UTMA Custodan or CESA Controller Name (CESA controller must be a parent or legal guardan of the CESA benefcary) Relatonshp to Mnor/Protected Person Date of Brth of Fducary (MMDDYYYY) State Governng UGMA/UTMA Ctzenshp of Mnor/Protected Person (Select One): U.S. Ctzen Resdent Alen Non-Resdent Alen Gender: Male Female Name of Mnor/Protected Person Socal Securty Number Address to be used on account: Please check here f ths s an address change. For alternate address requests, please submt Form 518. Date of Brth (MMDDYYYY) Cty State ZIP code 5E - Desgnaton of Successor Custodan for UTMA, Successor Controller for CESA, Successor Owner, Successor Annutant Ths desgnaton must be completed by the current Custodan/Controller/Fducary named n Part 5D. If ths desgnaton s for a Successor Custodan under UGMA/UTMA t must be wtnessed by a separate, dsnterested thrd party sgnng below. Ths desgnaton of Successor Custodan s not vald n the State of Oho. If ths desgnaton s for a Successor Controller under CESA, the person ndcated must be a parent/legal guardan of the CESA benefcary. Select One: Successor Custodan Successor Controller Successor Owner Successor Annutant Relatonshp to the Name of Successor Custodan/Controller/Owner/Annutant Mnor/Protected Person Date of Brth (MMDDYYYY) 5F - Annutant Change for Non-Qualfed Deferred Annuty Contracts (an annutant cannot be changed f the contract s owned by a non-person) Any annuty that s not an Advantage Fxed Seres, Bonus Fxed Seres, RAVA Plus, RAVA 4 or RAVA 5 Annuty has the followng restrctons: The current annutant must be alve. The contract cannot be n payout. The new annutant must be an owner. No ownershp changes must have occurred wthn the past 12 months, unless due to a documented dvorce settlement. No successor annutant can be named. Name as t appears n IRS Records Date of Brth (MMDDYYYY) Relatonshp to Current Owner(s) n Part 1 F120 Page 8 of 14
DOC0914F120 Part 6 Account Sutablty- Change of Ownershp Only Basc defntons for Investment Tme Frame, Rsk Tolerance, Investment Objectves and Lqudty Needs are provded below. More detaled descrptons and examples of some of the selectons can be found on your Sutablty Confrmaton. Complete the followng nformaton for each new account. For dvorces or change of annutant, we wll process the request wthout ths nformaton, but we wll requre t before you can commence tradng on the account. If you do not provde ths nformaton at ths tme t may delay future tradng. The nformaton n ths part s requred for changes of ownershp other than dvorces or change of annutant. Please Note: Based on product and ownershp lmtatons, the assets you are recevng may be transferred nto your exstng accounts, or combned from multple accounts nto one account wthn the same ownershp and product combnaton. If the sutablty nformaton provded on ths form conflcts wth the nformaton prevously on fle for an exstng account, the new nformaton wll replace the old. If you are recevng assets from multple accounts n the same product type (ncludng share class and strategy where applcable), and the sutablty nformaton you provded on ths form s not the same for all accounts of the same product type, we wll apply the sutablty nformaton gven for the last account of that product type lsted on the form. Account 1 - Complete all of the followng nformaton for each new account (from Part 1). Apply ths sutablty to all accounts. Sutablty to reman the same as the orgnal account Investment Tme Frame (Select only one) A. Less than 1 Year B. 1-3 Years C. 4-7 Years D. 8-10 Years E. 11+ Years Lqudty Needs (Select only one) A. Less than 1 Year B. 1-7 Years C.8+ Years Rsk Tolerance (Select only one) A. Conservatve B. Conservatve / Moderate C. Moderate D. Moderate / Aggressve E. Aggressve Investment Objectves (Select one per column n order of mportance) 1st 2nd 3rd A. Captal Preservaton C. Income D. Tax Consderatons E. Protecton F. Educaton G. Estate Plannng H. Speculaton I. Growth J. Growth wth Income "B. Captal Apprecaton" s no longer an opton. Check here f any addtonal New Owner Account Profle Informaton pages are attached. Investment Tme Frame Defnton Investment Tme Frame The expected perod of tme you plan to nvest to acheve your current fnancal goal(s). Rsk Tolerance Defntons Conservatve Conservatve / Moderate Moderate Moderate / Aggressve Aggressve You accept the lowest return potental, lowest return varablty, and the lowest fluctuaton n account value, n exchange for lower rsk. You accept a relatvely low return potental, relatvely low return varablty, and relatvely low fluctuaton n account value, n exchange for a below average amount of rsk. You accept an average amount of rsk n exchange for average return potental, average return varablty, and average fluctuaton n account value. You accept an above average amount of rsk n exchange for a relatvely hgh return potental, relatvely hgh return varablty, and relatvely hgh fluctuaton n account value. You accept the hghest amount of rsk n exchange for the hghest return potental, the hghest return varablty, and the hghest fluctuaton n account value. F120 Page 9 of 14
DOC1014F120 Investment Objectve Defntons Captal Preservaton The prmary goal s preservaton of captal over growth or ncome. Income The prmary goal s ncome provded by the nvestment (e.g. dvdends) rather than potental growth. Tax Consderatons The prmary goal s nvestments that mtgate federal, state and/or local taxes. Protecton The prmary goal s leavng a monetary beneft at death to loved ones or charty. Educaton The prmary goal s provdng/payng for educaton related expenses. Estate Plannng Speculaton Growth Growth wth Income The prmary goal s transferrng assets to loved ones and/or provdng a legacy at one's death. The prmary goal requres an acceptance of a hgher-than-average rsk and/or loss of captal n hope of makng a hgherthan-average return. The prmary goal s an ncrease n the captal or market value of the nvestment rather than ncome that may be receved from the nvestment. The prmary goal s to provde both growth and ncome, often by choosng nvestments whch have earnngs growth as well as dvdends. Lqudty Needs Defnton Lqudty Needs Perod of tme from the present untl you antcpate you may need access to some of the nvestment dollars. Addtonal Part 7 Clent Profle Clent Name Phone Number Ext. Number of Dependents Federal Tax Bracket Indvdual Annual Income Amount $ Net Worth Amount $ Lqud Net Worth Amount $ Investment Experence A. Are you employed by, or an assocated person of, a regstered broker-dealer, securtes exchange, or the Fnancal Industry Regulatory Authorty (FINRA)? Yes No B. Are you an offcer, drector, 10% shareholder or polcymaker of a publcly traded company? Yes No C. Employment Status Employer, Occupaton and Employer Address requred f Employed or Self-employed. A. Employed B. Self-employed C. Not Employed (unemployed, retred, student, mnor, homemaker) F120 Page 10 of 14
DOC1114F120 Employer Occupaton Employer Address Cty State ZIP code Country Part 8 Addtonal Requests and Requrements Supplemental Instructons for Brokerage, Amerprse ONE Fnancal Accounts and Amerprse Managed Accounts. Optons Tradng If the new owner s recevng an account that ncludes an opton contract, you must complete and submt Form 8340 - Opton Account Agreement. Fund of Hedge Funds If the new owner(s) or regstraton of the account s recevng Fund of Hedge Funds as a result of the change of ownershp, you must complete the Fund of Hedge Funds Applcaton (Form 291039). Addtonal requests that are not permtted on ths form are descrbed below: (To select one of these optons the clamant must complete, sgn, date and attach the approprate form to ths change of ownershp form). Ths Change of Ownershp/Annutant form can only be used to rettle the account assets n the name of the new owner or to change the annutant. Any addtonal requests must be submtted on the approprate form(s) and wll not be processed untl the ownershp or annutant change has been completed. Please also be aware that any arrangements, requests, nstructons and features set up on the orgnal owner's account may not be contnued for the new owner or account unless the approprate form s ncluded. Ths may nclude but s not lmted to scheduled payouts, delvery of dvdends or nterest, check wrtng or other features. Please speak to an Amerprse fnancal advsor for complete nformaton and forms specfc to your accounts. Some of the more commonly submtted requests are: Asset Movement Systematc Payout - Outgong Money Complete va Varable Annuty Transacton Request Form 33443 eforms - Money Movement Mutual Fund Funds Networkng Converson Form 224 Annuty Dvorce Surrender Form 131001 Bank Authorzaton - Incomng Money Complete va eforms - Money Movement Benefcary Desgnatons Transfer on Death/Payable on Death Advsors, use eforms - Lfe Insurance/Annuty Change of Benefcary Advsors use eforms - Benefcary Update. Clents please contact your advsor. Benefcary Update. Clents, please contact your advsor. Account Features Addtonal Account Features Form 15028 Look-Through Trust Documentaton Form for Form 200475 IRAs F120 Page 11 of 14
DOC1214F120 Part 9 Authorzaton and Acknowledgments - (Must be sgned by all new owners or fducares) The followng statements apply to all accounts: You confrm that you are at least 18 years of age and full legal age n your state of resdence. Householdng for Statements: You understand Amerprse Fnancal may use and combne nformaton concernng accounts owned by members of a prmary household group to provde members of the group wth paper and/or electronc statements of account(s) and certan account nformaton. These accounts nclude nvestment, nsurance, annuty and brokerage accounts. A prmary household conssts of an ndvdual, hs or her spouse or domestc partner, and any accounts owned for, by, or wth ther unmarred chldren under age 21 who resde at the same address. You understand that f you want to have a statement coverng only accounts that you own and to not partcpate n household prcng, you wll need to call your Amerprse fnancal advsor, or the toll-free number on your statement. Householdng for Shareholder Documents: You understand that Amerprse Fnancal Servces, Inc. may use and combne nformaton concernng accounts owned by members of a household to provde them wth a sngle paper copy of shareholder documents. Prospectuses, supplements, annual reports, semannual reports and proxes may be ncluded. Under ths, household s defned as two or more shareholders who share the same address and ether share the same last name or have ndcated that they are marred or domestc partners. Ths remans n effect unless notfed otherwse. You understand that f you wsh to contnue recevng multple copes of prospectuses, supplements, annual reports, semannual reports and proxes, you can call 1.866.273.7429 and reference the clent number found on your statement. Multple malngs wll resume wthn 30 days of the request. You acknowledge that you wll be bound by the terms of the nsurance polcy/annuty contract/account, as are your hers, executors, admnstrators and successors. Brokerage, nvestment and fnancal advsory servces made avalable through Amerprse Fnancal Servces, Inc. Member FINRA and SIPC. The followng statements apply to Brokerage and Managed Accounts only: You authorze Amercan Enterprse Investment Servces, Inc. to lend to tself or to others, ether separately or n common, any holdng n your account that Amerprse Fnancal Servces may be carryng for you on margn. You understand that you may borrow aganst your account at the rates and terms explaned n the clent agreements (non-qualfed accounts only). You realze that the clearng agent, Amercan Enterprse Investment Servces, Inc., wll release my name, address and securty poston to requestng companes n whch Amercan Enterprse Investment Servces, Inc. holds securtes for my account, unless you specfy otherwse to Amerprse Fnancal Servces. If the new account s a Non-Qualfed account, you acknowledge that you have receved the Amerprse Brokerage Clent Agreement and agree to abde by ts terms as currently n effect or as the terms may be amended from tme to tme. Ths account s governed by a predspute arbtraton clause, whch s found n Secton 28, page 3 of the clent agreement. I acknowledge recept of the predspute arbtraton clause. If the new account s a tax-qualfed account, You acknowledge that you have receved the Amerprse Brokerage Clent Agreement and agree to abde by ts terms as currently n effect or as the terms may be amended from tme to tme. Ths account s governed by a predspute arbtraton clause, whch s found n Secton 28, page 3 of the clent agreement. You acknowledge recept of the predspute arbtraton clause. The followng statement apples to Columba mutual funds only: You acknowledge that you have receved and read the 'Amerprse Account Agreement - Columba Only' and agree to abde by ts terms as currently n effect or as they mght be amended from tme to tme. You hereby consent to all those terms and condtons wth full knowledge and understandng of the nformaton contaned n the Agreement. Ths account s governed by a predspute arbtraton clause that s found n Secton 23, page 2 of ths Agreement. You acknowledge recept of the predspute arbtraton clause. The followng statements apply to IRAs (excludng annutes): You appont Amerprse Trust Company as custodan of your IRA and understand that the Indvdual Retrement Custodal Account Agreement n Your Gude to IRAs and your IRA applcaton, f applcable, comprse your custodal agreement wth Amerprse Trust Company. You assume all responsblty for any tax consequences and penaltes that may result from makng contrbutons to, transactons wth, or dstrbutons from your IRA. You acknowledge that any IRA benefcary desgnaton you submt wll apply to all nvestment accounts and products held n ths IRA plan. You authorze Amerprse Trust Company to nvest, drectly or ndrectly, n deposts of tself or ts afflates that bear a reasonable rate of nterest to facltate cash sweep servces. F120 Page 12 of 14
DOC1314F120 Taxpayer's Identfcaton Number to Be Used Name Assocated Wth Ths Tax Number (on IRS Records) W-9 TIN Certfcaton Check approprate box for federal tax classfcaton (requred): Indvdual/Sole propretor Partnershp Corporaton Trust C-Corporaton Revocable (Optonal Addtonal Trust Detals) S-Corporaton Irrevocable (Optonal Addtonal Trust Detals) Lmted Lablty Company (LLC) Estate C-Corporaton Other S-Corporaton Partnershp Check here f owner s an Exempt Payee (defned n Form W-9 nstructons) Exempt Payee code: 1-An organzaton exempt from tax under secton 501(a), any IRA, or a custodal account under secton 403(b)(7) f the account satsfes the requrements of secton 401(f)(2), 2-The Unted States or any of ts agences or nstrumentaltes, 3-A state, the Dstrct of Columba, a possesson of the Unted States, or any of ther poltcal subdvsons or nstrumentaltes, 4-A foregn government or any of ts poltcal subdvsons, agences, or nstrumentaltes, 5-A corporaton, 6-A dealer n securtes or commodtes requred to regster n the Unted States, the Dstrct of Columba, or a possesson of the Unted States, 7-A futures commsson merchant regstered wth the Commodty Futures Tradng Commsson, 8-A real estate nvestment trust, 9-An entty regstered at all tmes durng the tax year under the Investment Company Act of 1940, 10-A common trust fund operated by a bank under secton 584(a), 11-A fnancal nsttuton, 12-A mddleman known n the nvestment communty as a nomnee or custodan, 13-A trust exempt from tax under secton 664 or descrbed n secton 4947 Foregn Account Tax Complance Act Reportng A FATCA exempton code s requred for persons submttng ths form for accounts mantaned outsde of the Unted States by certan foregn fnancal nsttutons. If you are only submttng ths form for an account you hold n the Unted States, no code s requred. Otherwse, submt IRS Form W-9 separately. As used below, the word I refers to the applcant who s the taxpayer on the account. Under penaltes of perjury, I certfy that: 1. The number shown on ths form s my correct taxpayer dentfcaton number, and 2. I am not subject to backup wthholdng because: (a) I am exempt from backup wthholdng, or (b) I have not been notfed by the Internal Revenue Servce (IRS) that I am subject to backup wthholdng as a result of a falure to report all nterest or dvdends, or (c) the IRS has notfed me that I am no longer subject to backup wthholdng, and 3. I am a U.S. ctzen or other U.S. person (defned below), and 4. The payee s exempt from Foregn Account Tax Complance Act (FATCA). Certfcaton Instructons: As used below, the word You refers to the applcant who s the taxpayer on the account. Check ths box f you have been notfed by the IRS that you are currently subject to backup wthholdng because you have faled to report all nterest and dvdends on your tax return. Defnton of a U.S. person. For federal tax purposes, you are consdered a U.S. person f you are: An ndvdual who s a U.S. ctzen or U.S. resdent alen, A partnershp, corporaton, company, or assocaton created or organzed n the Unted States or under the laws of the Unted States, An estate (other than a foregn estate), or A domestc trust (as defned n Regulatons secton 301.7701-7). Non-U.S. persons should submt the approprate Form W-8. Form W-9 and Form W-8 and ther nstructons are avalable upon request or on rs.gov. F120 Page 13 of 14
DOC1414F120 The Internal Revenue Servce does not requre your consent to any provson of the document other than the certfcatons requred to avod backup wthholdng. The Internal Revenue Servce does not requre your consent to any provson of the document other than the certfcatons requred to avod backup wthholdng. Owner or Fducary Name All New Owners/Fducares of the accounts dentfed n ths form Must Sgn Here State Date Sgned X MMDDYYYY) Jont Owner/Fducary Name X Date Sgned (MMDDYYYY) Servcng Advsor Informaton! Do not complete ths secton f you wll not act as the servcng advsor of the named benefcary. Name Advsor ID Advsor Sgnature X Team ID Comp % Phone Ext Date (MMDDYYYY) Branch Offce Number Co-Advsor Informaton Name Advsor ID Advsor Sgnature X Team ID Comp % Phone Ext Date (MMDDYYYY) Branch Offce Number F120 Page 14 of 14