BROKERAGE ACCOUNT APPLICATION
Yes
Do you have any other accounts with Scottrade or
its affiliates (Scottrade Bank / Boulevard Bank)?
Account
Type:
No
Please view Page 3 for a list of account types.
Primary Applicant / Organization Information
Depending on account type, this may be the minor, protected person or organization (trust, corporation, partnership, etc.)
Name of Individual/Organization
Mr.
Mrs.
Ms.
Dr.
Email Address
First
Middle
Street
Home
no P.O. Boxes or mail receiving / incorporation services
City
Cell
Work
ZIP
State
Mailing Address
Phone Numbers - check preferred
Suffix
Date of Birth / Effective Date Social Security / Tax ID #
account notices will be sent here
Primary Physical Address
Last
ext.
Fax
include city, state & ZIP - if a mailing address is not provided, account notices will be sent to the primary physical address
Individual, Joint, Retirement & Minor Account Applicants - complete the rest of this page, then proceed to Page 2
All Other Account Types - complete the Expected Account Activities section, then proceed to Page 2
Citizenship
1. Are you a U.S. citizen?
2. Are you a citizen of any other non-U.S. countries?
Countries:
Employment Status:
Retired
If you will be in the U.S. 183 days or less, contact us at 866.246.1788.
Yes - proceed to question 2.
No - complete section at right.
Employed
Homemaker
Country:
Yes - list below
Unemployed
Student
Self-employed /
business owner
Job Title
Job Description
Employer
Employer Address
Yes - Permanent Resident Card Number:
Are you a permanent
U.S. resident?
No - Visa type:
Expiration Date (MM/DD/YYYY):
Employer Industry Code* Occupation Code*
*See p.3 for a code list or
contact us for assistance.
Please provide the following information to help us understand your financial status. Scottrade will not use this information to supervise the suitability of any transaction
in your account.
$25,000 - $49,999
1. What is your annual income?
$0 - $24,999
$50,000 - $99,999
$100,000 - $249,999
$250,000+
$0 - $24,999
$25,000 - $49,999
$50,000 - $249,999
$250,000 - $499,999
$500,000+
2. What is your household net worth (excluding residence)?
Affiliations
This information is to comply with requirements mandated by the U.S. Government and other regulatory agencies, and to better understand your intentions for your brokerage account.
Yes - Scottrade will inform the securities firm, exchange or FINRA of your intention to maintain this account and provide copies of
1. Are you employed by / affiliated with
confirms, statements & other requested information. Provide organization name & compliance address in the field below.
No
a securities firm, exchange or FINRA?
Yes - provide company name & CUSIP / symbol in
2. Are you or a member of your household a control person / affiliate of a public company as defined by the SEC?
the "Required Information" space below.
This generally includes 10% shareholders, members of the Board of Directors and policy-making officers.
No
3. Are you currently, or have you ever been, a
high-level elected / appointed government official?
Yes - select from the
following:
No
U.S. Federal Gov't Official
U.S. State Governor
Yes - provide name, country, relationship & position in space below.
No
4. Do you have an immediate family member or close associate who
is or was a high-level elected / appointed government official?
5. Do you receive compensation, directly or indirectly, from a business related to or
engaged in the growth, sale or distribution of marijuana or products containing marijuana?
Required
Information
for "yes"
responses:
Yes
No
U.S. City Mayor
Senior Executive / Director of a Gov't-owned Non-U.S. Entity
Non-U.S. Gov't Official - provide country & title here:
Country:
Title:
Expected Account Activities
Yes
No
1. Do you plan to trade low-priced, over-the-counter securities ("penny stocks")?
Yes
No
2. Do you plan to deposit or transfer-in low-priced, over-the-counter securities?
Employment Wages
Gift
Inheritance / Trust
3. What best describes the initial
Legal Settlement
Lottery / Gaming
Retirement Funds
funding source for this account?
Employment Wages
Gift
Inheritance / Trust
4. What best describes the ongoing
Retirement Funds
Spouse / Parent Support
Savings
source of funds for this account?
5. Do you anticipate initiating/receiving international ACH or wire transfers?
6. What is the expected frequency of these international transfers?
7. What is the expected annual international transfer total?
8. Indicate purpose(s) for these international transfers:
Commission / Payroll
Business Expense / Income
*SF1000*
SF1000/11-15
Investments
Other - describe:
Savings
Spouse / Parent Support
Unemployment / Disability
Investments
Legal Settlement
Lottery / Gaming
Unemployment / Disability
Other describe:
Yes - list non-U.S. countries to be
No - proceed
involved in these transfers (below):
to Page 2.
Once or twice per year
$0 - $9,999
$10,000 - $49,999
Charitable Payment
Investment / Real Estate Opportunity
Other - describe:
Once every few months
$50,000 - $99,999
Once a month
$100,000 - $249,999
Personal Remittance
Personal Purchase of International Goods
Several times per month
$250,000 - 499,999
$500,000+
Vacation / Travel
Non-U.S. Asset Management
Page 1 of 2
Your Investment Profile
Provide the following information to help us understand your investment and trading style. We will not use this information to supervise the suitability of any transaction in your account.
Active trading Relatively frequent trading Long-term - buy &
Timely investing - trading infrequently
Unsure - I am
1. How do you primarily plan
when I see opportunity in the market
based on market movement
on a daily basis
new to investing
hold investing
to use this account?
121 - 249
0 - 24
25 - 120
250+
2. Over the past 12 months, how many trades were placed across all of your brokerage accounts?
(0 - 2 per month)
(3 - 10 per month)
(11 - 20 per month)
(21+ per month)
Co-Applicant / Authorized Person Information
This may be a custodian, trustee, guardian, trading officer or other authorized representative. For additional co-applicants, complete and attach one Co-Applicant Page per person.
Name of Individual/Organization
Mr.
Mrs.
Ms.
Dr.
First
Middle
Last
Suffix
Phone Numbers - check preferred
Home
Email Address
Date of Birth / Effective Date Social Security / Tax ID #
Cell
Primary Physical Address
no P.O. Boxes or mail receiving / incorporation services
Street
City
Mailing Address
Work
ZIP
State
ext.
optional
Citizenship
1. Are you a U.S. citizen?
2. Are you a citizen of any other non-U.S. countries?
Countries:
Employment Status:
Retired
If you will be in the U.S. 183 days or less, contact us at 866.246.1788.
Yes - proceed to question 2.
No - complete section at right.
Employed
Homemaker
Country:
Yes - list below
Unemployed
Student
Are you a permanent
U.S. resident?
Self-employed /
business owner
Job Title
Job Description
Employer
Employer Address
Yes - Permanent Resident Card Number:
No - Visa type:
Expiration Date (MM/DD/YYYY):
Employer Industry Code* Occupation Code*
*See p.3 for a code list or
contact us for assistance.
Please provide the following information to help us understand your financial status. Scottrade will not use this information to supervise the suitability of any transaction
in your account.
$25,000 - $49,999
$0 - $24,999
$50,000 - $99,999
$100,000 - $249,999
$250,000+
1. What is your annual income?
$0 - $24,999
$25,000 - $49,999
$50,000 - $249,999
$250,000 - $499,999
$500,000+
2. What is your household net worth (excluding residence)?
Affiliations
This information is to comply with requirements mandated by the U.S. Government and other regulatory agencies, and to better understand your intentions for your brokerage account.
Yes - Scottrade will inform the securities firm, exchange or FINRA of your intention to maintain this account and provide copies of
1. Are you employed by / affiliated with
confirms, statements & other requested information. Provide organization name & compliance address in the field below.
No
a securities firm, exchange or FINRA?
Yes - provide company name & CUSIP / symbol in
2. Are you or a member of your household a control person / affiliate of a public company as defined by the SEC?
the "Required Information" space below.
This generally includes 10% shareholders, members of the Board of Directors and policy-making officers.
No
3. Are you currently, or have you ever been, a
high-level elected / appointed government official?
Yes - select from the
following:
No
4. Do you have an immediate family member or close associate who
is or was a high-level elected / appointed government official?
U.S. Federal Gov't Official
U.S. State Governor
Yes - provide name, country, relationship & position in space below.
No
5. Do you receive compensation, directly or indirectly, from a business related to or
engaged in the growth, sale or distribution of marijuana or products containing marijuana?
Required
Information
for "yes"
Responses:
Yes
No
U.S. City Mayor
Senior Executive / Director of a Gov't-owned Non-U.S. Entity
Non-U.S. Gov't Official - provide country & title here:
Country:
Title:
Margin - Sign below ONLY if you are applying for margin privileges (not available to all account types).
By signing below, I acknowledge that I have received, read and agree to abide by the Margin provisions (Section IV) of Scottrade's Brokerage Account Agreement.
X
Primary Applicant's Signature
Date
X
Co-Applicant/Authorized Person's Signature
Signatures - The following certifications and acknowledgements apply to all persons signing this application.
Under penalties of perjury, 1) The taxpayer identification number entered above is correct and belongs to me.
2) I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not
I certify that:
been notified by the IRS that I am subject to backup withholding as a result of failure to report all interest
or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding.
3) I am a U.S. person (including a U.S. resident alien).
4) Any FATCA code(s) entered on this form indicating that I am exempt from FATCA reporting
is correct. (Applies to foreign organizations only. Not applicable to Scottrade accounts.)
Date
If you are subject to backup
withholding, check here:
By checking this box, I understand
that item 2 does not apply to me.
BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE RECEIVED, READ AND AGREE TO THE TERMS OF THE
SCOTTRADE BROKERAGE ACCOUNT AGREEMENT, WHICH CONTAINS A PRE-DISPUTE ARBITRATION PROVISION ON
PAGE 11, SECTION VII-B, WHICH MAY BE ENFORCED BY THE PARTIES. I FURTHER AGREE THAT MY UNINVESTED
CASH BALANCES MAY BE SWEPT INTO THE SCOTTRADE SWEEP PROGRAM AS DESCRIBED IN THE AGREEMENT.
The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.
X
Primary Applicant's Signature
SF1000/11-15
Date
X
Co-Applicant/Authorized Person's Signature
Date
Page 2 of 2
This is a reference page; you do not need to return it.
List of Available Account Types - Input the account type you're opening in the New Account Type field on Pages 1 & 2.
Additional documents may be required. Contact your local Scottrade team with questions.
Individual
Joint - include type
Qualified Plan - include type
l Community Property
l 401(k)
Custodial
l Keogh
Conservatorship/Guardianship l Tenants in Common
l Tenants by Entirety
l Profit Sharing
Trust
l With Rights of Survivorship (WROS) l Money Purchase Pension
Estate
l Defined Benefit Plan
SIMPLE Plan
Outside Custodial IRA
Usufruct
IRA - include type
l Coverdell ESA
l Inherited
l Rollover
l Roth
l SEP
l SIMPLE
l Traditional
Corporate/Partnership - include type
l Association/Non-Corporate
l Corporate
l Investment Club
l LLC (Limited Liability Company)
l LLLP (Limited Liability Limited Partnership)
l LLP (Limited Liability Partnership)
l LP (Limited Partnership)
l Partnership
l Sole Proprietorship - Unincorporated Entity
Employer Industry Codes - Input the 3-digit bolded code most closely associated with your industry in the Employer Industry Code field on Pages 1 & 2.
Accounting A11
Advertising/Marketing A21
Aerospace/Defense A31
Agriculture/Farming/Ranching A41
Amusement and Recreation A51
Animal Services and Veterinary A61
Architecture/Design A71
Arts/Antiques A81
Athletics/Fitness A91
ATM/Vending Machines A22
Automotive A32
Aviation B11
Bar/Nightclub/Adult Entertainment Club C11
Childcare C21
Cleaning/Janitorial/Housekeeping C31
Communications/Telecommunications C41
Construction/Carpentry/Landscaping C51
Convenience Store/Liquor Store/Gas Station C61
Customer Service and Support C71
Education E11
Embassy/Consulate E21
Energy E31
Engineering E41
Fashion/Clothing F11
Financial Services - Banking/Depository Institutions F21
Financial Services - Brokerage/Investment Advisory/
Securities Exchanges F31
Financial Services - Venture Capital/Financing (Non-Bank) F41
Firearms and Explosives F51
Forestry, Fishing, Hunting and Trapping F61
Gaming/Casino/Card Club G11
Government/Public Administration G21
Grocery/Supermarket G31
Healthcare/Medical Services H11
Hotel/Hospitality H21
Import/Export I11
Information Technology (IT) I21
Insurance I31
Jewelry, Gems and Precious Metals J11
Justice, Public Order and Safety J21
Legal Services L11
Logistics/Supply Chain L21
Manufacturing M11
Maritime M21
Media/Entertainment M31
Mining, Oil and Gas M41
Money Services Businesses (Check Cashing, Money
Transmitting, Payday Loans, Currency Exchange) M51
Museums, Art Galleries and Botanical and Zoological
Gardens M61
Non-Profit/NGO (Non-Government Agency)/Charity N11
Parking and Car Washes P11
Pawn Shops/Brokers P21
Personal Care/Hygiene (Beauty, Salon, Cosmetics,
Massage, etc.) P31
Pharmaceuticals P41
Printing/Publishing P51
Private Household P61
Professional/Civic Organizations (Non-Retail) P71
Retail Estate R11
Religious Organization R21
Repair Services - Home, Auto and Other R31
Restaurant/Food Service R41
Retail Sales/Retail Trade R51
Science and Biotechnology S11
Security S21
Transportation - Freight and Warehousing T11
Transportation - People (Rail, Air and Ground) T21
Travel T31
Utilities (Public) U11
Wholesale Sales/Trade W11
Occupation Codes - Input the 3-digit bolded code most closely associated with your occupation in the Occupation Code field on Pages 1 & 2.
Accountant/CPA/Bookkeeper/Controller A42
Actuary A52
Adjuster A62
Administrator A72
Advertiser/Marketer/PR Professional A82
Agent A92
Air Traffic Controller A33
Ambassador/Consulate Professional A43
Analyst A53
Appraiser A63
Architect/Designer A73
Artist/Performer/Actor/Dancer A83
Assistant A93
Athlete A44
Attendant A54
Attorney/Judge/Legal Professional A64
Auctioneer A74
Auditor A84
Barber/Beautician/Hairstylist B21
Broker B31
Business Executive (VP, Director, etc.) B41
Business Owner B51
Caregiver C81
Carpenter/Construction Worker C91
Cashier C22
Chef/Cook C32
Chiropractor C42
Civil Servant C52
Clergy C62
Clerk C72
Compliance/Regulatory Professional C82
Consultant C92
Contractor C33
Counselor/Therapist C43
Customer Service Representative C53
Dealer D11
Developer D21
Distributor D31
Doctor/Dentist/Veterinarian/Surgeon D41
Driver D51
Engineer E51
Examiner E61
Exterminator E71
Factory/Warehouse Worker F71
Farmer/Rancher F81
Financial Planner F91
Fisherman F22
Flight Attendant F32
Human Resources Professional H31
Importer/Exporter I41
Inspector/Investigator I51
Intern I61
Investment Advisor/Investment Manager I71
Investor I81
IT Professional/IT Associate I91
Janitor J31
Jeweler J41
Laborer L31
Landscaper L41
Lending Professional L51
Manager M71
Mechanic M91
Military, Officer or Associated M22
Mortician/Funeral Director M32
Nurse N21
Nutritionist N31
Office Associate O11
Other O21 If Other, include both occupation code and a
description in the Occupation Code box.
Pharmacist P81
Physical Therapist P91
Pilot P22
Police Officer/Firefighter/Law Enforcement Professional P32
Politician P42
Project Manager P52
Registered Rep R61
Researcher R71
Sailor/Seaman S31
Salesperson S41
Scientist S51
Seamstress/Tailor S61
Security Guard S71
Social Worker S81
Teacher/Professor T41
Technician T51
Teller T61
Tradesperson/Craftsperson T71
Trainer/Instructor T81
Transporter T91
Underwriter U21
Writer/Journalist/Editor W21
*SF2039*
SIMPLE Individual Retirement Account
PARTICIPANT’S NAME AND ADDRESS
SF2039/8-15
SIMPLE IRA CUSTODIAN’S NAME, ADDRESS AND PHONE
Scottrade, Inc.
P.O. Box 31759
St. Louis, MO 63131-0759
Social Security Number
Home Phone
Date of Birth
S IMPLE IRA
Account Identification
Business Phone
Employer’s Plan Name
Employer’s Name, Address and Phone
E-mail Address
CONTRIBUTION INFORMATION
Contribution Date
Contribution Amount
Check here if this is a transfer SIM
PLE IRA.
DESIGNATION OF BENEFICIARY(IES)
The following individual(s) or entity(ies) will be my primary and/or contingent beneficiary(ies). If neither primary nor contingent is indicated, the individual or
entity will be deemed to be a primary beneficiary. If more than one primary beneficiary is designated and no distribution percentages are indicated, the
beneficiaries will be deemed to own equal share percentages in the SIMPLE IRA. Multiple contingent beneficiaries with no share percentage indicated will also
be deemed to share equally. If any primary or contingent beneficiary dies before I do, his or her interest and the interest of his or her heirs will terminate
completely, and the percentage share of any remaining beneficiary(ies) will be increased on a pro rata basis. If no primary beneficiary(ies) survives me, the
contingent beneficiary(ies) will acquire the designated share of my SIMPLE IRA. If no beneficiaries are named, my estate will be my beneficiary. I understand that I
may change or add beneficiaries at any time by completing and delivering the proper form to the trustee or custodian. The trustee or custodian has provided no tax or
legal advice to me regarding my beneficiary designations.
No.
I elect not to designate beneficiaries at this time and understand that I may designate beneficiaries at a later date.
Social Security
Relationship
Beneficiary’s Name and Address
Date of Birth
Number
Primary or
Contingent
Share %
1.
Primary
Contingent
%
2.
Primary
Contingent
%
3.
Primary
Contingent
%
4.
Primary
Contingent
%
SPOUSAL CONSENT
This section should be reviewed if either the trust or the residence of the
Participant is located in a community or marital property state and the
Participant is married. Due to the important tax consequences of giving
up one's community property interest, individuals signing this section
should consult with a competent tax or legal advisor.
CURRENT MARITAL STATUS
I Am Not Married – I understand that if I become married in the future, I
must complete a new SIMPLE IRA Designation Of Beneficiary form.
I Am Married – I understand that if I choose to designate a primary
beneficiary other than my spouse, my spouse must sign below.
CONSENT OF SPOUSE
I am the spouse of the above-named Participant. I acknowledge that I have
received a fair and reasonable disclosure of my spouse's property and
financial obligations. Due to the important tax consequences of giving up my
interest in this SIMPLE IRA, I have been advised to see a tax professional.
I hereby give the Participant any interest I have in the funds or property
deposited in this SIMPLE IRA and consent to the beneficiary designation(s)
indicated above. I assume full responsibility for any adverse consequences
that may result. No tax or legal advice was given to me by the Custodian.
________________________________________
(Signature of Spouse)
__________________
(Date)
SIGNATURES
Important: Please read before signing.
I understand the eligibility requirements for the SIMPLE IRA and I state that I
do qualify to establish a SIMPLE IRA. I have received a copy of the
Application, the 5305-SA Plan Agreement, the Financial Disclosure and the
Disclosure Statement. I understand that the terms and conditions which
apply to this SIMPLE IRA are contained in this application and the Plan
Agreement. I agree to be bound by those terms and conditions. Within seven
(7) days from the date I open this SIMPLE IRA, I may revoke it without
penalty by mailing or delivering a written notice to the Custodian.
I assume complete responsibility for:
1. Determining that I am eligible for a SIMPLE IRA each year I make an
elective deferral.
2. Ensuring that all contributions I make are within the limits set forth by
the tax laws.
3. The tax consequences of any contribution (including rollover
contributions) and distributions.
_______________________________________
__________________
(Participant)
(Date)
_______________________________________
__________________
(Authorized Signature of Custodian)
Page 3 of 3
(Date)
(Rev. 5/2012)