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IRA APPLICATION
Ameritrade
lnstitutional
Account #
Advisor #
Case #
INVESTMENT ADVISOR
lnvestment Advisor Firm (Agent) and Primary Contact
Primary Contact;
Firm Name:
o
PLEASE SELECT THE TYPE OF IRA YOU WANT (SELECT ONLY ONE TYPE OF ACCOUNT)
'Per IRS regulations, emplolprs are responsible tor maintaining a SEPISIMPLE Adoption
Agreement for thair Plan. but thesa do not need to be sent to TD Ameritrade.
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Please @mplete minor's infomation in section 2. The responsible individual must
@mplete an Account Application Supplement Fom, initial in Sections I and 9,
as applicable, and sign in Section 10.
ACCOUNT OWNER: COMPLETE ALL INFORMATION BELOW FOR THE PRIMARY OR MINOR ACCOUNT OWNER
First Name;
Middle lnitial: I Last Name:
Social Security Number:
Date of Birth:
Primary Telephone
Number:
E
Check here if this is not a U.S. phone number.
Se@ndary Telephone
Number: I
Check here if this is not a U.S. phone number.
Home Street Address (no Po boxes)
City:
State:
ZIP Code:
State:
ZIP Code:
Mailing Address (if different from abovell
City:
Source of income (if Unemployed, Retired. Hamemaker, or Studant):
Please specify if you are:
I
f]
Unemployed IRetireo !Homemaker Estudent
Employer Name (ff seff-employed. please Novide the name of yout business and industry)
Employed El self-employed
Occupation:
Type of Business:
Employer Street Addressi
Country of Citizenship fFor non-U.S. Citizens and Permanent Residents)l
Check here if you are a:
IU.s.
citizen EPemanentResident
INota
U.S. Citizen
Country of Birth (For non-U.5. Citizens and Permanent Resdent9:
country of Dual or Secondary citizenshig 0f awlicable):
Non-U.S.citizens: DoyouholdacurentU.s.immigratimvim?
nCheck here il
"
[Yes ENo
Specifuvistype:
--Expiratim:
you or your spouse, any member of your immediate family, including parents, in-laws. siblings, and dependents. and any personal or business associates is a
lSRfi Specify tire name of tlie SPF, political title, relationship to Account owner, and country of office
senior polrticai figure
-VisaNumber:
ECheck here if you or your spouse, any member of your immediate family, including parents, in{am. siblings, and dependents.
-ing
I
ztP vode.
State:
City:
is a
dir*tor,
10% shareholder, or policy-mak-
offlcer of apublicly traded company. Specify the company name address, city, and state:
Check here if you or your spouse, any member of your immediate family, including parents, in-lam, siblings,,and dependents is licensed,.employed by, or associated with, a
required authorization letter (with this appliction):
I
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Page 1 of 4
TDAI 1468 REV O9/14
CASH SWEEP VEHICLE CHOICES (SELECT ONLY ONE)
E
TD Ameritrade FDIC lnsured Deposit Account
(lDA)
E
TD Ameritrade Cash (Protected by the Securities lnvestor Protection
Corporation (SIPC))
Pays interest on credit balances.
lf
not specified, all credit balances will automatically be swept daily to the TD Ameritrade FDIC lnsured Deposit Account. See the Client Agreement for a
complete description of the Cash Sweep program.
NOTE:
DEATH BENEFICIARY INFORMATIONName (Flrst, Middle lnitial, Last):
Social Security Number
Date of Birth:
Helatonsnrp:
Tvoe of Beneficraru:
Ierimary
fiContingent
EPer Stirpes.'
Share %:
EPer Stirpes"
Share %
Stirpes--
Share %
EPer Stirpes"
Share %:
EPer Stirpes'.
Share %:
LlPer Stirpes"
Share
Name (F,rst Middle lnitial, Last):
Social Security Number:
Date of Birth:
Relationship:
TvDe of Beneticiarv:
Ierimary
[Co'ntingent
Name (FreI, Middle lnitial, Last).
Social Security Number:
Date of Birth:
Relationship:
Tvoe of Beneficiarv
Ierimary
Econlingent
EPer
Name (Fre( Middle lnitial, Last).
Social Security Number:
Date of Birthi
Relationshipl
Tvoe of Beneficrarv.
['erimary [Co'ntingent
Name (First, Middle lnitial, Last).
Smial Security Number
Date of Birth
Tvoe of Beneticiarv.
Relationship:
Ierimary [coirtingent
Name (First, Middle lnitial, Last)
Date of Birth
socral secunty NumDer:
Tvoe of Beneficrary.
Relationshipl
['Primary [Co'ntlngent
70:
Thb sactlon should be reviowsd lf thg r$ldonce of tho account ownsr i3 locatod in a community prop€rty or marltal property Btata, and the accouni owner
lB
merried and is not naming lheir spouse as 3ole primary beneficiary. Due to tho important tax consequences of giving up one's community property intergst,
indiyidualr signing thb section should consult wlih a tax or logal adyisor.
No tax or legal advice was given to me by the Cuslodian.
Signature o,
Spouse:
Dale:
dollar amounts. Unless olhemise noted, proportions are deemed to be in equal share. lt a lrusl ,s designaled as a beneficiary, then the trust title and UA date must be provided.
have attached a separte sheet wih addilional beneficiaries. TD Amerilrade
ll additional space is required, please aftach a separcte sheet wilh additional beneliciaies.
reseves the right to require addilional information upon my death to verity lhe identity ot intercsts of beneliciar or beneficiaies- TD Amedtado resstws the right lo rquest
whatever documentation it deems appropriate before making dislibutions to a beneticiary or beneficiaries.
"fur Stirpes shall mean: each branch ol the decndent's family shall inheil in equal parts and by way of represenlalion. Please nota lhat the "For Srirpes'dosignation carries
certain legal and tax implications, and may not be Nailable in all states. TD Ameritrade cannot advise whether a "Per Stirpes'eleclim is apprcpriate for tha Ac@unt Owne/s
tax or estate planning. Please consuft an estate planner for details regading this designation.
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CONFIRMATION AND STATEMENT PREFERENCES
By providing your email address, you consent to receive electronic trade confirmations and statements. Account statements and trade
confirmations detailing any purchase or sale of a security will be sent to the email address on record unless you choose to have them sent to
the mailing address of remrd by checking below.
fl
Monthly Paper Statements
E] Monthly Electronic Statemenls
I
I
Paper Trade Conflrmations
Electronic Trade Confi rmations
Email Address:
lf no email address is provided then it will default to monthly paper statements and paper trade confirmations.
Amerikade will provide my name to corporations whose securities I hold in my account for the purpose of additional corporate
communications, unless I have checked here.
ITD
Page2ol 4
TDA| 1468 REV 09/14
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DUPLICATE STATEMENTS & CONFIRMS FOR AN INTERESTED PARTY
lf you would like to provide duplicate paper statements and/or duplicate paper trade confirmations to an interested party please complete the
information below:
Please check all that
o
apply
I
Statements
I
Trade Confirmations
Name:
Company Name (if any):
Street Address:
City:
State:
I ZIP Code.
PROXY AUTHORIZATION
Please select one of the below choices. lf no selection is made TD Ameritrade will default to sending me proxies. The Agent can only vote my
proxies if they have discretion over my account.
E I would like to receive and vote on proxies.
E Agent receives and votes proxies. I hereby authorize
E
'
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TD Ameritrade to foruard prory soliciting materials, annual reports, and other related
issuer materials, normally sent to me, to my advisor (Agent) and to allow Agent to vote Proxies on my behalf.'
Agent receives and votes proxies but I would like to receire informatjonal copies. I hereby authorize TD Ameritrade to forward proxy soliciting
materials, annual reports, and other related issuer materials, normally sent to me, to my advisor (Agent) and to allow Agent to rote Proxies on
my behalf.-
I confirm that the Agent holds discretionary authority over my account pursuant to an advisory contract with the Agent. I understand that this authorization may be
rescinded at any time for any reason, by a written notice addressed to TD Ameritrade and delivered to your oflice. Thas authorization shall extend to the benefit of your
succ€ssors and assigns.
LIMITED POWER OF ATTORNEY
UM]TED TO PURCHASE AND SALE OF SECURITIES, INCLUDING THE TRADING OF OPTIONS, IF APPUCABLE.
By my initials in Section 8. and to the e)dent indic€ted herein, I hereby constitr,ne and appoint the Advisory Firm or indMdual named herein as my agent and attorney-in-fact
("Agent"), to buy, Bell, and trade in stocks, bonds, and any other securiiies and/or contracts relatirE to the same an a@ordance wfi the Client Agreement (incorporat€d ry
reference) applicable to this account held in my name, or number on your books, without notice to me. My Agent is authorized to effect such transactions in my account via
any available medium, electronic access or olh€Mise, including but not limited to electronic access via personal mmputer or touch-tone phone.
lf I hare signed an oplions agreement, my Agent is specifically authorized to effect options lransactions in my account, up to my approval level. I have received a
copy of the booklet'Characteristics and Risks of Standardized Options." I hereby agree to indemnily and hold harmless TO Ameritrade, lnc. ("TD Ameritrade"), its
affilaates and their directors, officers, employees, and agenls from and against all claims, actions, costs, and liabilities. including attorneys'fees, arising out of or
related to reliance on this authorization and to pay promptly on demand any and all losses arising therefrom or debit balance due thereon. In all such purchases,
sales, or trades, you are authorized to follow the instructions of my Agent in every respect concerning my account with you; and my Agent is authorized to act for
me and on my behalf in the same manner and with the same force and effect as I might or could do wilh respect to such purchases, sales, or trades, as well as
with respect to all other things necessary or incidental to the furtherance or conduct of such purchases, sales, or trades, including without limitation the delivery of
securities or monies from the account in the Account Owner's or Owners' name and the provasion of securities cost basis method selection and/or information for
purposes of cost basis or tax reporting.
I hereby ratify and confirm any and all transactions with you heretofore or hereafter made by my Agent for my account. This authtrization and indemnity is in
addition to, and in no way limits or restricts, any rights which you may have under any other agreement or agreemenls between me and TD Ameritrade. lf this is
a fiduciary account, Account Owner(s) affrm(s) that this grant of limited trading authority has been conferred consistent with any fiduciary duties or powers of
Account Owne(s).
This authorization is a continuing one and shall remain in full force and effect until (i) you are noti{ied by a written notice delivered to TD Ameritrade of my death
or incapacity or (ii) I change or revoke this authorization by a written notice to TD Ameritrade. You shall have no duty of inquiry. Until you receive such written
revocation, you are entitled to act in reliance on this authorization and indemnity. Any revocation of this authorization shall have no effect on any liability which
results from transactions initiated before you receive written notice of revocalion. This authorization and indemnity shall inure to the benefit of your firm and of any
successor firm or firms, irrespective of any change or changes at any time in the personnel thereof for any causes whatsoever, and of the assigns of your present
lirm or any successor firms.
I have carefully read this power of attorney and indemnity and understand that it authorizes my Agent named herein to exercise rights and powors over
my accounts as if I had exercised them myself and that my Agent's aciions and instructions with respect to my accounts are fully binding on me. lalso
undenstand and agr6e that TO Ameritrade has no duty or responsibility to monitor trading in my accounts by my Agent or noti{y me prior to accepting
instruciions, I understand that Agent will automatically receive duplicate confirmations and statements unless I request othertyise.
Ac6unt Owner's/Responsible lndividual's lnitials:
o
I hereby authorize the Agent listed on
page
1 to execute trades in my account
AUTHORIZATION TO PAY FEES TO AGENT
By my initials in Section 9, and to the extent indicated herein, I hereby authorize TO Ameritrade, lnc. ("TD Ameritrade") to pay Agent from my account the Agent's
management fees as in\oiced by Agent. I also authorize TD Ameritrade to liquidate shares of any money market mutual fund I may hold in my account to the extent
necessary to pay such fees. TD Arneritrade shall rely on Agent's inroices and have no responsibility for the calculation or verification of fees.
I will indemnily and hold TD Ameritrade and its affiliates, directors, officers, employees. successors, and assigns harmless from all losses, claims, damages,
liabilities, and costs, including attorneys'fees, which TD Ameritrade may incur by relying upon representation of Agent or upon this authorization.
This authorization will remarn rn full force and effect until revoked by me by a written notice addressed and delivered to TD Ameritrade.
Ac@unt owner's/Responsible lndividual's
lnitials:
I
t trereby authorize TD Ameritrade to pay my Agent's fee from my account as
directed by my Agent.
Page 3 of 4
TDAI 1468 REV 09t14
idual Rotiren€nl Plan and
statos hr6r
j!)"'#. r'ilioliiiil#
u,i.r irn;ccoJnt |s subl& b rul€s and resulalons ot th6 unrt6d
'rax
for lhe inlorma on co'larnsd h ls ,*
respo;sib'lrty
i
accept
nnanoal
consequences.
ana
servic€ and thar rhs tundrng or rhs eccounr may ;; i,gnfi;nr
lii";;;ry-;;a- ior rrarmressro rriearioa and iD Amedrrad€ cr€anns, rnc' r,om anY and
soDrrcarion and a6m such inrormar,on s uue ano''J,.iil i'iii!"-ti
pursuant lo this Agreemonl'
ta"en
acuon
r€sulting
hom
anv
for
damsg€s
;iiil;'il il-cEfu
and read the cuslodial Agrc€m6nt, I undersland lhat
cJstodEr As€emenr, whict i= ,nco,po"ateo oy
maks the fo[owing declaratjon: Having rsceived
I d€sbnats TD A.noritlBd€ cl€anng, tnc. as cu$od;n and
Th,s documsnt consl utes
rirn -e or rrom a propeitv aooo,nteo invesun€nl manag€r'proceeds
rhe cuslod,n wr, rn/€st ano rern/."r ny ac.oum;;6e;'Jnii *iir, on .tio.
willb€ hold ar
irit secu,itres orvrdends. ario
uiri-i".
r,,nv
mv aurho.*v ro axec-r€ a1t"a""
"uct'nsrt
inslrucid'
oih€rwis€
tnc
unless
ctea'ing.
i6
ra conffi"li,J.i"Jliil-il-it!'*jrr *o
i.rado.
For
tfftivldu.l (contrlbutory) lRAr: I dlrBcr
TD
ln
Ametltr.d. cloadng, lnc. to msintsln my deducllblo' rolldtt snd dir'ct rollov" contrlbutlon(3)
'
Contributo.Y lRA.
mooey€arnecttromprcperty,tnta,estoroiriremirJ,;;r*i.*r*dt;."p*sionorannuiiya3doienBdcomp€nsatonorasad€hrr€di|lcentilBaaEld
wili rsmain in tull forcs
and
Th,s D.sEnation of B€nelioarv
of Bensficiary wilt b6 efleclive on the date received by the custodian
F.) m€ and ,n sucr fo'm end s-ubstanc€ as rhe
of Denencjary sis;d
-t
unirlsuch rime as rhe cusooian rs rn
this Asr€€ment
rffioG"3r"r,.r* "" 1."g". av€ ds risht to r€csrv€ b€nefns undor
custodian deons ne.cessa.y rr r cr,ang€ rhe
I undersrand this oesignation
.fe.,
aauaiie';lp"i;;'"il";";;i;;-".;hanse
uenei;;i[]";$;ijav ii
lacknowlodoethallhavelec€lvedandleadthe-cledAgreem€nt,'avallabl€atwwvradvrsgsertE€sco.nolDvcalling80G43l3500'lhalwllgovsrnmy
accouni.Iaqr€€lob€boJnouyrtre-ctrentlg,s€ie-.jw'nict,mayueamenoeotomtmetolmeandwhEhrsinclrpdreiedbythisr€ierenc€.Irel€as€and
purcuanl !o
haDrlity and chms fo'damaqes resultos flo,n anv achon tak€n
ao|r€ !o ind€mnrfy End hotd harmbss lD Am6m;d;'i;Jft;;ii.;;;;r;d
"r diii uJi"rrmauon contsln€d n th. apptic€ton is tru6 and corr'ct.l h€€bv
s-i. A"-"me^r Bv mv sonarurc rr€ro,v. r a*o,riiilf'JiiiiIi'
"ki;"6i;idi iv-riie,i,i,itJiJ i..tn.,tbmr.-an a;ount b€ open€d in he nEme s€r lo4h below'
jniji"'&Iiil-l;
;##i";i;di
lhal willgolBrn mv sccount
by th€ 'cli€nt Aore€m€nl_.and. arry supDlemental opt'orc agro€m€nts
-"u_a"'uy
lf I hav€ roqueslBd an options:rcount, lag€€ to b€ bound
erifianges and the opti:ons cleanng corporaton and will nol violale
optioni
luro
ri*ed
oi
rn"
it'"
r
ai'6
ioconrraas'
opuona
trEding
of
-,n,oi*O
eoolicable to lne
Jch nsk6 and wilhstand
,n opt ons n aug an! represent lh?i I am {inancialry able lo be;' s
posoon and exerc,se trmrts. t am awa,e o? iie",si""
currenr
optrons-trading losses.
lnc. (th€'cl6edng Firm'), unless oth€rwise instruct€d
A[ sscudti{*, dvil€nds, and pr@e€ds wil b€ hetd at ID Ameitrada cl€anng.
may b6 ;6ssd on.info;mau;n contain€d in a consumd or crsdit report,
leoitimala busine$ purpose", lnv 0""'"ion w mX,i;,itii-".risiiiiuoiiiil6 &"na i,edn
Frrm
clsadng
th€
lnstilutlon.l
and
ir,i pori",,i" dr rD Ame'rilEd€
to conBumsr
relEroino lhls ac'ount' rncludind accounl d6lmouencv and Yolunlary clo6JrEs
I undsdsnd that TD Ar*dtrad€ lnstn.rtional fiEy relatg infotmatDn
asoncv trom whch lhev hev€
i"i'ti'ri'itLt'iir 'nr"''n ,ne a e'"1' ;'nsumer or c'si'it rsoortno
or cr'oit r€port ns as€na€s. Upon mv roqu€sr' ,'o i,iiJlu"il"
I
lho
d
dispulo
agenci€s
ipoti' iiiimenteae rn*rtutonat agrees to notrt' itre consumer or ct€i[ro€po4ing
obtanod endor 'eoorlad firy *n",ln"' ol'
am€rn€de lnstitJdonal to obiain
I aihorze
o'ro"'
rnv
sEnitu'e
tiv
"'"on
ru'n'i#i
comol€lan€$ o. accuracy ot $e intrmabn
con;umer or c-€dit r€Port6 for lho narne(s) set icrlh b€low'
TD Amedrade lnstltutonal are not insurEd by th€ F€d€ral Depc(
unl6s spsclf€d olh6r*$e, I understand tnat nondeposi investnents purchased through
insfir'rtron ano are suqed to invesunent nsk and loss thal mav o(ce€d th€
tnsurance corporation (FDtcl are not
pdncipal inv€stsd.
gor.rnm.nr figrrr th. funding ol trlotism .nd mdr.y hund.titrg acthdti"'
LnEdtnr inio.rndon lbour p.oc.duEs ro, oFnlng ! nd rccounu To hGlp dre
ua idcrtin . Grd, p€r6on who op.ns an 'ccounl
i^a .io'u
i".ft,ri-,, t i i6ii'",
tr
ablt of birlh, and oihor inior'naton ih'ar will slbu u' to ld'trtry you'
lddreq
your
na|rr,
iot
wlll
aat
E
you:
you
an
accounq
oron
Yvlrr
wh.t thb fiarrE ior
r". s cey or volr d.ivd3 ric.nt. or orh" idc,'tirvrns doclI|l'n!''
thet ihe fundino of this account is subject io lhs rul€s and
undorstand
account.I
lrnto
the
Thi3 aoolicrfioh ,rovrd.3 ior $a dapoait ot tunat! or aacui
rul€6 and ros'rlation; nav have importanr and possibrv n€vocabre
6uch
ry
rnt"ln"r
n"*nrlJ
-rD
dubidns or the untud srrt""
Ame'rrada cr€adns rnc ro d€posir ih€ funds or
i"nesr r,"t u,e i,n-iinJinformarion iovroed ,s true and co.,ecr, aurhonze
tuno,ns transaction. t rslease and as'Ee to indemnirv and hold harmless
irliillp5""',oiiiiv
sscuriti€s accofttins ro th€ tundrns
'nsrrudlons,ri"'uir-itv-iii' cLi,s ki'd"."s€i r,om any edvdrs€ cons€quences th€t mav result
"i'J.iiii
ly6 #il;;1ilil;onai
oor'ga!ons';i?A;;;;;:;;fi;;;"lJ
i"ri,-"tiiii"il i"a- -i
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iu''iiJ"i; i'iiiili?iiri"li jdr"
lri;s
a;;;!!.j'ii
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ili;i;-;;;;i
iffi;A;-,ind;'ff;';;ilyi;,'#"d- p;##;;,#;'i
;fffi;;;;6;-,;iccs.
ib;ffi;;; cHft: #. roni",,v "no "u
rss1nds nghls which ro Ameritrade lnstitutional and li€ clsadng Firm mav have
succaa3ora and Hatn, This Authonzation suppbm;n6 and in noway limrts or
adm,;i$rarors. suc6ess6rs, and assasns and wll benoft TD AmeritEde
;";ruors,
m&
This
tuthoE;n;;;i;,;J;i;:;,
with
under any orh6r asreem€nt
lrctlMio;alEnd the Cleadng Firm's succ€sso.s and aesons'
prdiapuie arbitsatl,on
Ths Clhnt AerB€fiant appllc5bta to thi! brokaraga sccount egrr.mant contalns
or u,. .grcci.ii, iid;aing 6r eibitr.tbn as]€am.nt loc't d in
liil [ i. il,iiJ liul;t. .'
By 3igning thir tgGom'rlt, th' p'rll.a
ol lho cll'nt asru€m'nl on p's' 8'
chualt.
kion
12
{2) I tm nol subioct lo
corr€cl ta,Er6r id.ntilic.tior numbtr.
und.r p.ndti.3 of p.rju7y, I c.rriry rhet: (1) th;mblr 3hown on this iorm is my nor bce; n&itild bv th€ lnt'n.l R6,Gnue
'nd scryic. (lRs) th.r I
th;..
rb)
r
am
ercmpt
b€nure:
b.d(up wirhhotdins
t.t
or divid€_nds, o. tc) th.lRs has nolifi.d m.ihlr lam no lons.r subi'cr
rm 6ubi.cr to b5d(up w hr,oraing ." . ,c"rrt or-i L]Li-6 ipon
"rr
th. FATCA codsis) onlerDd on lhlsform (if.ny) lndlcatlngthtt I rlrl
tn)
(3)
t.m.
u.s.
cn;;iiiiiius-1p".".r,
wtrhhotdtng,.nd
to b.ckup
"no
i3
contci.
r.porting
film
FATCA
or.mpt
r6pon lll lhtat!.t .rd
R6renu. scrylc. (lRs)_ihat I .m subjsct to brckup withholding b.cause I h.vc f.il€d to
iliiiii,i*iiii"riii'e,o'
iir'.i,
tf I h.vc bccn
iiriii"ia.
notii.d by th. tht.rn.t
tai,rn, I muct c'o33 out (2)
- ;it:i
in lhis
c.riillcstjon'
AaEo.rr( Owr€/s,/Responsible lndividual's Pnnlsd Namoi
Dato
Account Own6/s/Responsible lndividual's Signatu€:
TD
Arncrltr.de ln3tilutional
PO 80X 919094
San Diego, CA
m
929-9094
TDAI1468 REV 0914
jdntly orrrled by
membols FlNRlvslPc To AmedtEde is a badema
AmedtEde lnstjtutional, DMsion of TD Amedhade, lnc.,and TD Ame,itrd€ Cle€ring, lnc.,
Used wflh permission
rsservsd'
lnc
All
rights
lP
Company
TD
Ameduade
2014
Bank.
O
TD Ar*nhade lp Company, lnc., and The Toro;tcgominion
Page4d4