Request to Release Ownership
of Worthless Securities
Fax to: (416) 413-0733
1. CLIENT INFORMATION
CLIENT NAME (LAST)
(FIRST)
ACCOUNT NUMBER
ADDRESS
CITY
POSTAL CODE
Please sign the letter below and return to B2B Bank Discount Brokerage ("B2BBDB")
2. RELEASE OF SECURITIES
To: B2B Bank Discount Brokerage
SECURITY:
NO. OF SHARES/UNITS:
MARKET VALUE:
My monthly statement presently shows that I am the owner of the above noted shares/units. I acknowledge that as of the
date of this letter, the shares/units have been de-listed/ceased trading/gone bankrupt/or into receivership. I acknowledge
that my shares/units cannot be sold. I further acknowledge that B2BBDB is unable to deliver the shares/units to me.
I would like to sell these shares/units but cannot do so. Thus, I no longer wish to show ownership of these shares/units in
my account indicated above.
I hereby instruct B2BBDB to remove these shares/units from my account. I release B2BBDB from any claims to
these shares/units including any claim resulting from any future value of the shares/units (resulting from mergers and
acquisitions with other companies) and distributions in the form of dividends, interest or shares/units.
X
AUTHORIZED CLIENT SIGNATURE
MMDDYYYY
199 Bay Street, Suite 610 PO Box 35 STN Commerce Court Toronto ON M5L 0A3
B2B Bank Discount Brokerage if a division of B2B Bank Securities Services Inc. (an IIROC member, Member – Canadian Investor Protection Fund).
B2B Bank is a trademark used under license.
226-05-013E (07/02/2014)