EFTA01464639.pdf

Account Transfer Form Instructions Complete all sections according to the instructions below. Please print or type all information. Return the completed form to your financial organization. NOTE: You must attach your most recent statement to process this account transfer. For an internal transfer (for instance, a transfer of assets between two introducing broker-dealers who clear through Pershing) the statement is not required. I. RECEIVING FIRM INFORMATION (Only one per form) ■ Provide your Pershing account number. ■ Provide your Social Security Number (SSN) or Tax Identification Number (TIN) ■ If the account is a joint account, provide the SSN or TIN for the joint owner. ■ Provide the two character account type code that most accurately describes your account. II. DELIVERING ACCOUNT INFORMATION ■ Provide the clearing firm number. If there is no clearing firm number, enter the delivering firm name, contact name, and telephone number. ■ Provide the original account number of the account you are delivering to Pershing. ■ Provide the account title as it appears on your statement for the account you are transferring. III. TRANSFER TYPE (Chose only one) Indicate the type of transfer you are requesting by checking the appropriate box. Pershing will only transfer positions in kind for retail accounts. For nonretirement accounts, the quickest way to liquidate your assets is to call your existing financial organization and place a sell order. In order to ensure that the trade is executed at the time and price you want, request to have the proceeds check mailed directly to you. When you receive the check, mail it (including your account number on the check) to: PERSHING, ONE PERSHING PLAZA, 14TH FLOOR, JERSEY CITY, NEW JERSEY 07399, ATTENTION: MONEY DESK. ■ A Direct Registration System (DRS)/Direct Reinvestment Plan (DRIP) transfer is a transfer of a position held directly at the transfer agent. ■ A direct mutual fund transfer is a transfer in kind of a direct mutual fund position from the mutual fund company. ■ Bank retirement plan accounts involve transfers of retirement plans at banks with CDs, checking accounts, or savings accounts. Please indicate if you want to liquidate immediately or defer these instructions until maturity date. Please contact your financial organization to stop any automated rollover reinvestments. (Please read section V and sign when applicable.) IV. PARTIAL TRANSFERS, DIRECT MUTUAL FUNDS AND LIQUIDATIONS If you selected Partial Transfer, use this section to specify the appropriate assets for a partial transfer. If you selected Direct Mutual Fund Transfer, use this section to identify the mutual fund positions to transfer. ■ Liquidation instructions will only be accepted from non-National Securities Clearing Corporation (NSCC) firms. EFTA01464639 ■ Select a dividend and capital gain option for direct, in kind mutual fund transfers. If a box is not checked, Pershing will process the transfer as reinvest, for dividend and capital gain options. V. RETIREMENT PLAN RESTRICTIONS AND CERTIFICATIONS If you are transferring a retirement account and are over the age of 70 1/2, read this section carefully. Contact your investment professional or financial organization if you have any questions. ■ The new custodian must provide the appropriate paperwork. ■ For retirement accounts for which Pershing LLC acts as the custodian or servicing agent, you must pay all termination fees to your prior custodian before you can transfer assets. Any deposit made to your Pershing LLC custodian account to reimburse fees after the transfer shall be processed as a current year contribution. NOTE: If you are transferring from a trustee, make the appropriate selection. If you have selected someone other than Pershing LLC as custodian, have your investment professional or financial organization obtain the necessary signatures to accept custodianship. VI. PARTICIPANT SIGNATURE AND CERTIFICATION ■ Sign and date the form. ■ The form must be signed, dated, and signature guaranteed within 90 days of its receipt. 09-PWM-0597 (10/09) Page 1 of 3 EFTA01464640 Account Transfer Form I. RECEIVING FIRM INFORMATION (Only one per form) RECEIVING FIRM CLEARING NUMBER: 0443 ACCOUNT NUMBER: N4 G 0238 1 SOCIAL SECURITY NUMBER SECONDARY SOCIAL SECURITY NUMBER: ACCOUNT TYPE: (Enter the two character code) Non retirement: Retirement: Other: CO SN-(Single) JT—(Joint) TR—(Trust) CT—(Cotrustee) CO—(Corporate) CU-- (Custodian) ES—(Estate) BC—(Bank Custody) AG—(Agency) IR—(Traditional IRA) RI—(Roth IRA) DR—(Direct Rollover) BI—(Beneficiary) BR-- (Beneficiary Roth IRA) 4K-(401k) EI—(Education Savings Account) SI-(SIMPLE IRA) QP—(Qualified Plan) 4B—(403b) 7B—(457 Plan) HS—(Health Savings Account) 5P—(529 Plan) OT—(Other) II. DELIVERING ACCOUNT INFORMATION CLEARING NUMBER: ACCOUNT NUMBER: FIRM NAME: ACCOUNT TITLE: (As it appears on your statement) 2427984920101 JP Morgan Southern Trust Company, Inc 2 or TAXPAYER IDENTIFICATION NUMBER: or TAXPAYER IDENTIFICATION NUMBER: 66 07 7 9 8 6 1 DELIVERING FIRM CONTACT INFORMATION (MANDATORY WHEN CLEARING NUMBER IS NOT PROVIDED) CONTACT NAME: FIRM ADDRESS: (No. P.O. Box) CITY: EFTA01464641 STATE: TELEPHONE NUMBER: NOTE: A complete copy of your most recent statement is necessary to process this form. III. TRANSFER TYPE (Choose only one) A. ACCOUNT TRANSFER u FULL (Check one below) u TRANSFER ALL ASSETS IN KIND (Skip to Section VI) u LIQUIDATE ALL ASSETS LISTED IN SECTION IV (Liquidations are not for brokerage accounts) u TRANSFER ALL ASSETS IN KIND EXCEPT FOR THE ASSETS LISTED IN SECTION IV, WHICH REQUIRE LIQUIDATION u PARTIAL (Complete Section IV) B. DRS/DRIP u FULL (Check one below) u SELL FRACTIONS AND CLOSE ACCOUNT u TRANSFER ALL FULL SHARES ONLY u PARTIAL (List assets in Section IV) NOTE: For transfer agents, electronically send positions or issue a certificate for whole shares and redeem fractional shares. C. DIRECT MUTUAL FUND u TRANSFER MUTUAL FUNDS FROM THE ACCOUNT HELD DIRECTLY AT THE FUND COMPANY (See list in Section IV for exact instructions) NOTE: Only one fund family per form. D. BANK RETIREMENT PLAN ACCOUNTS (Select only one) u LIQUIDATE IMMEDIATELY AND TRANSFER CASH I am aware of and acknowledge any penalty I will incur from an early withdrawal. u LIQUIDATE AT MATURITY AND TRANSFER CASH Specify maturity date: (submit two to three weeks before maturity date). NOTE: Liquidations involving bank CDs, checking accounts, or savings accounts can only be processed from retirement accounts. ZIP: IV. PARTIAL TRANSFERS, DIRECT MUTUAL FUNDS AND LIQUIDATIONS SIGNATURE DATE SIGNATURE DATE 09-PWM-0597 (10/09) Page 2 of 3 EFTA01464642 Account # N4G-023812 IV. PARTIAL TRANSFERS, DIRECT MUTUAL FUNDS AND LIQUIDATIONS (If there are more than eight assets, attach a signed list to this form) QUANTITY ASSET DESCRIPTION 96,088.87 2,200 US Dollar US Dollar CUSIP®/SYMBOL OUSDPRAA7 OUSDPRAA7 -1 PS US Gold Put 74347W9DI -19 PS US Gold Put 74347W9D3 FUND ACCOUNT NUMBER TRANSFER INSTRUCTIONS1 DIVIDEND OPTION2 CAPITAL GAIN OPTION2 u Transfer in Kind J Liquidate Cash u Reinvest Cash u Reinvest u Transfer in Kind J Liquidate Cash u Reinvest Cash u Reinvest u Transfer in Kind J Liquidate Cash u Reinvest Cash u Reinvest u Transfer in Kind J Liquidate Cash u Reinvest Cash u Reinvest u Transfer in Kind J Liquidate Cash u Reinvest Cash u Reinvest u Transfer in Kind J Liquidate Cash u Reinvest Cash ▪ Reinvest u Transfer in Kind J Liquidate Cash u Reinvest Cash ▪ Reinvest u Transfer in Kind J Liquidate Cash u Reinvest Cash ▪ Reinvest 1 If you have requested a liquidation, your market price is not guaranteed. You will receive the current market price after your transfer request is received, reviewed, and determined to be in good order by the delivering firm. Pershing is not responsible for market fluctuations or delays in the review process. DRS items cannot be liquidated. 2 If this is a mutual fund transfer and there is no dividend or capital gain option checked in the section above, Pershing will process this request as reinvest. (FOR OFFICE USE ONLY: All transfers must be added to Pershing's transfer systems) V. RETIREMENT PLAN RESTRICTIONS AND CERTIFICATIONS ■ Age 701/2 restrictions: If you are at least the age of 701/2 ESTIMATED S VALUE this year and you are transferring or rolling over assets from an IRA, qualified plan or 403(b) account, you may be required to take a minimum distribution (RMD) from your qualified plan or 403(b) account before rolling over your assets. ■ Rollover Certification of Employee: I understand the rules and conditions and I have met the requirements for making a rollover. Due to the important tax consequences of rolling over funds or property, I have been advised to see a tax professional. All information provided by me is true and correct and may be relied on by Pershing LLC. I assume full responsibility for this EFTA01464643 transaction and will not hold Pershing LLC liable for any adverse consequences that may result. I hereby irrevocably designate this contribution in funds or other property as a transfer or rollover contribution. TO THE PRIOR TRUSTEE: u Pershing LLC accepts appointment as successor custodian. u Please be advised that (Insert Firm Name) SUCCESSOR CUSTODIAN'S SIGNATURE: VI. PARTICIPANT SIGNATURE AND CERTIFICATION To the Delivering Firm Named Above: If this account is a qualified retirement account, I have amended the applicable plan so that it names as successor custodian the trustee listed above. Unless otherwise indicated in the instruction above, please transfer all assets in my account to Pershing without penalties, such assets may be transferred within the time frames required by NYSE Rule 412 or similar rule of the NASD or other designated examining authority. Unless otherwise indicated in the instructions above, I authorize you to liquidate any nontransferable proprietary money market fund assets that are part of my account and transfer the resulting credit balance to the successor custodian. I authorize you to deduct any outstanding fees due to you from the credit balance in my account. If my account does not contain a credit balance, or if the credit balance in the account is insufficient to satisfy any outstanding fees due to you, I authorize you to liquidate the assets in my account to the extent necessary to satisfy that obligation. If certificates or other instruments in my account are in your physical possession, I instruct you to transfer them in good deliverable form, including affixing any necessary tax waivers, to enable the successor custodian to transfer them in its name for the purpose of the sale, when, and as directed to me. I understand that upon receiving a copy of this transfer information, you will cancel all open orders for my account on your books. I affirm that I have destroyed or returned to you credit/debit cards and/or unused checks issued to me in connection with my brokerage account. I understand that you will contact me with respect to the disposition of any assets in my brokerage account that are nontransferable. SIGNATURE GUARANTEED BY: CLIENT'S SIGNATURE: JOINT CLIENT'S SIGNATURE: DATE: DATE: Please attach your most recent brokerage account statement to process this account transfer. INVESTMENT PROFESSIONAL'S NAME: EFTA01464644 INVESTMENT PROFESSIONAL'S PHONE NUMBER: 09-PWM-0597 (10/09) Page 3 of 3 CUSIP® belongs to its respective owner. DATE: does hereby accept appointment as successor custodian. EFTA01464645