CUSTOMER ACCOUNT TRANSFER FORM NOTE: You must attach your most recent statement for this transfer to be processed.
Internal transfers do not require a statement.
Complete the following numbered sections accordingly (please print or type all information): 1. Provide your receiving Pershing account number. 2. Provide your Social Security Number or Tax Identification Number. For joint accounts, provide both numbers. 3. Provide the original account number of the account you are delivering to Pershing. 4. For nonautomated account transfers, enter the delivering firm name, contact name, and telephone number. 5. Provide the account title as it appears on your account statement for the account you are transferring. 6. Provide the street address of the delivering firm. 7. Use this section to indicate the type of transfer you are requesting by checking the appropriate box. NOTES: ■ An Automated Customer Account Transfer Service (ACATS) transfer is a transfer of all assets, in kind, from another NSCC member firm (generally, when using ACATS, money market funds will be liquidated; proprietary funds should be liquidated prior to submitting this form) ■ ■
■ ■
If you are requesting an ACATS transfer, go to section VI A non-ACATS transfer is a transfer of partial assets from a financial organization, or a transfer of assets from a non-NSCC member firm (for instance, a bank, credit union, mutual fund company, etc.) An internal transfer is a transfer of assets between two introducing broker-dealers who clear through Pershing A broker-dealer change must be indicated when transferring a retirement account that is maintaining the original trustee (for instance, if you are retaining your present custodian)
8. Use this section to indicate the type of account you are requesting to be transferred by marking the appropriate box. NOTE: The Customer Account Transfer Form should be used for all direct rollovers (retirement accounts). 9. If you selected non-ACATS as the transfer type, please select the appropriate option and complete the applicable information. NOTES: ■ You should complete liquidations for mutual funds, money market funds, and partial transfers before submitting the transfer request to Pershing ■
Certificates of Deposit are only processed for retirement accounts
10. Use this section if you are requesting a partial transfer or a direct mutual fund transfer. NOTE: Select a dividend and capital gain option for a direct in-kind mutual fund transfer (If an option is not selected, Pershing will process the transfer as cash). 11. If you are transferring a retirement account and are over the age of 70½, please read this section carefully. You should speak with your investment professional or financial organization if you have any questions. 12. Sign and date the form. If there are two signatures, there must be two Social Security Numbers in Section I of the form. NOTE: The form must be signed, dated, and signature guaranteed within 90 days of its receipt. 13. If you are transferring from a trustee, make the appropriate selection. If you have checked someone other than Pershing LLC as Custodian, have your investment professional obtain the necessary signatures to accept custodianship. NOTE: Have the new custodian provide their paperwork to Pershing. Special note 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 your assets. Any deposit made to your Pershing LLC custodian account to reimburse fees after the transfer shall be processed as a current year contribution.
r. 1-03 RPD-150 ACAT 1-03
CUSTOMER ACCOUNT TRANSFER FORM
RECEIVING FIRM CLEARING NUMBER: 0443 DELIVERING FIRM CLEARING NUMBER: _______________
I. RECEIVING FIRM INFORMATION (ONLY ONE PER FORM) (1) ACCOUNT NUMBER:
(2) SOCIAL SECURITY OR TAX IDENTIFICATION NUMBER:
SECONDARY SOCIAL SECURITY OR TAX IDENTIFICATION NUMBER:
(4) FIRM NAME:
CONTACT NAME AND TELEPHONE NUMBER: (FOR NON-ACATS ONLY)
II. DELIVERING FIRM ACCOUNT INFORMATION (3) ACCOUNT NUMBER: (5) ACCOUNT TITLE (AS IT APPEARS ON YOUR STATEMENT):
(6) STREET ADDRESS: (NO P.O. BOX)
NOTE: A complete copy of the client’s most recent statement (dated within 90 days) is necessary to process this form, unless this is an internal Pershing transfer.
III. ACCOUNT INFORMATION (7) TRANSFER TYPE:
❏ ACATS
(8) ACCOUNT TYPE: ❏ SN–SINGLE ❏ CU–CUSTODIAN ❏ IR–IRA ❏ EI–EDUCATION SAVINGS ACCOUNT
❏ NON-ACATS
❏ INTERNAL TRANSFER
❏ BROKER-DEALER CHANGE REQUEST
❏ ES–ESTATE ❏ RI–ROTH IRA ❏ OT–OTHER
❏ CO–CORPORATE ❏ AG–AGENCY
❏ DR–DIRECT ROLLOVER ❏ 4K–401(K)
❏ SI–SIMPLE IRA ❏ CT–COTRUSTEE
❏ BC–BANK CUSTODY ❏ QP–QUALIFIED PLAN
❏ JT–JOINT ❏ TR–TRUST
IV. DISPOSITION INSTRUCTIONS (9) Check only one of the following: ❏ TRANSFER ALL ASSETS IN-KIND. (NOTE: Proprietary money market funds that are not transferable MUST be liquidated and transferred as cash.) ❏ DIVIDEND REINVESTMENT PLAN. Issue a certificate for all whole shares, redeem fractional shares, and issue a check. (See attached delivery instructions.)
❏ LIQUIDATE ALL ASSETS AND TRANSFER AS CASH. (NOTE: Not valid for NSCC/ACAT-eligible firms.) ❏ LIQUIDATE CERTIFICATES OF DEPOSIT IN MY RETIREMENT PLAN IMMEDIATELY. I am aware of and acknowledge the penalty I may incur from my early withdrawal. ❏ LIQUIDATE AT MATURITY, FORWARD PROCEEDS OF MY CERTIFICATES OF DEPOSIT FROM MY RETIREMENT PLAN. Maturity Date: _________________________________
V. PARTIAL AND DIRECT MUTUAL FUND TRANSFERS (10) ❏ PARTIAL TRANSFER. Transfer only the assets and quantities indicated below. (NOTE: If there are more than four assets, attach a signed list to this transfer form.) ❏ TRANSFER FROM DIRECT MUTUAL FUND ACCOUNT. (NOTE: Only one fund family per form.) Please indicate Transfer In-Kind or Liquidation below. QUANTITY
ASSET DESCRIPTION
CUSIP ®/SYMBOL
DIVIDEND OPTION
FUND ACCOUNT NUMBER
CAPITAL GAIN OPTION
❏ Transfer In-Kind ❏ Liquidate ❏ C ❏ R ❏C ❏R ❏ Transfer In-Kind ❏ Liquidate ❏ C ❏ R ❏C ❏R ❏ Transfer In-Kind ❏ Liquidate ❏ C ❏ R ❏C ❏R ❏ Transfer In-Kind ❏ Liquidate ❏ C ❏ R ❏C ❏R ❏ Transfer In-Kind ❏ Liquidate ❏ C ❏ R ❏C ❏R NOTE: If it 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 cash (if eligible). Please check “C” for Cash or “R” for Reinvest.
VI. AGE 70 1/2 RESTRICTIONS (11) The following restrictions apply to a retirement account transfer: If you are the age of 70 ½ or older, you may not roll over your required minimum distribution (RMD) from a qualified plan. If necessary, please instruct your plan administrator to distribute your RMD prior to the rollover of your assets.
VII. 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 below. Unless otherwise indicated in the instruction above, please transfer all assets in my account to Pershing without penalties; such assets may not be transferred within the time frames required by NYSE Rule 412 or similar rule of the National Association of Securities Dealers (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 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 by 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 securities account. I understand that you will contact me with respect to the disposition of any assets in my securities account that are nontransferable.
SIGNATURE GUARANTEED BY:
(12) CLIENT’S SIGNATURE:
DATE (MUST BE COMPLETED):
JOINT CLIENT’S SIGNATURE:
DATE (MUST BE COMPLETED):
(13) TO THE PRIOR TRUSTEE: ❏ Pershing LLC accepts appointment as successor Custodian. We have established an account as described in Internal Revenue Code Sections 402(c)(8)(B). ❏ Please be advised that __________________________________________does hereby accept appointment INSERT FIRM NAME as successor custodian. SUCCESSOR CUSTODIAN’S SIGNATURE: CONTACT: Pershing LLC ACAT
DATE: TELEPHONE ACATS (201) 413-2374 NUMBER: NON-ACATS (201) 413-4571/4591
NAME OF INVESTMENT : PROFESSIONAL: BRANCH:
Trademark(s) of DLJ Long Term Investment Corporation. CUSIP® belongs to its respective owner.
TELEPHONE NUMBER: r. 1-03 RPD-150 ACAT 1-03
