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POWER OF ATTORNEY
INFORMATION FORM
This form must be submitted in conjunction with the original Power of Attorney*
Account Holder’s Name
Account number
power of attorney’s name
social security number
date of birth
COUNTY
STATE
ZIP CODE
COUNTY
STATE
ZIP CODE
Physical address (no P. O. boxes)
CITY
MAILING ADDRESS (IF DIFFERENT FROM PHYSICAL ADDRESS)
CITY
*In addition, the Power of Attorney must be signed by the appointed individual or a copy of the individual’s
driver’s license must be provided. Before submission the Power of Attorney must be notarized by a Notary
Public.
SIGNATURE
Account Holder Signature
Date
P. O. BOX 451340 • WESTLAKE, OH 44145 • PHONE: 877-693-8208 • FAX: (440) 366-3755 • WWW.TRUSTETC.COM • EMAIL: [email protected]
EQUITY TRUST COMPANY, CL235F, Rev 12/11/13