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| | | |ACCOUNT TRANSFER AUTHORIZATION |Piper Jaffray Account Title |
| | | | | |
| | | | |Account Number |Rep. No. |
| | | | | | |
| | | |Complete online, print & sign as appropriate. | |
|“X” One : ACAT & Non-ACAT Processed by HQ: BTIN | Non-ACAT processed by Branch: BTNA |Piper Jaffray Clearing No.: 311 |
|A. TYPE OF TRANSFER |
|“X” One |“X” One | | |
|Total Partial |Cash/Margin |Coverdell Education Savings Account (ESA) |IRA |
|Broker/Dealer Change |Qualified |Direct Rollover (attach former employer’s distribution form) |Roth IRA |
|B. DELIVERING FIRM ACCOUNT INFORMATION |
|Firm Name | |Account Number |Clearing Number |SSN/TIN (Primary) |
|& Address | | | | |
|(6 lines max.) | | | | |
| | | | | |
|(Address required| | | | |
|if | | | | |
|Non-ACAT) | | | | |
| | |Account Title (from prior statement) |SSN/TIN (Secondary) |
| | | | |
| | | | |
| | | | |
|C. TRANSFER INSTRUCTIONS - (Complete ONLY part 1, 2, 3 or 4 below). |
|1. BROKERAGE OR TRUST COMPANY |
|“X” One |1. Transfer ALL assets In-kind (Do not Liquidate) 2. Liquidate entire account and transfer. 3. Transfer only assets listed below. |
|Quantity |Description Of Asset (Attach additional sheet if necessary). |Action (For # 3 above only) |
| | | Liquidate | Transfer In-kind |
| | | Liquidate | Transfer In-kind |
| | | Liquidate | Transfer In-kind |
|2. BANK, SAVINGS & LOAN OR CREDIT UNION (See page two for delivery instructions). |
|Cash Options | Full Transfer (all cash in account) | Partial Transfer (must provide exact amount) Only $ | | |
| | | | | |
|CD / Annuity | Liquidate IMMEDIATELY. I am aware of and acknowledge the penalty I will incur from early withdrawal. |
|Options | Liquidate at MATURITY. Maturity date: | |(Please submit 2-3 weeks before maturity date). |
| | | | |
|3. MUTUAL FUND COMPANY - (Use a separate form for each Mutual Fund Company) |
|Name of Fund |Fund Account # |# of Shares or “All” |Handling (“X” One) |Omnibus Account |
| | | | |(Piper Jaffray Use) |
| | | |Transfer Shares In-Kind |Sell & Transfer Cash | |
| | | | | | |
| | | | | | |
| | | | | | |
|Mutual fund dividends and capital gains will automatically reinvest. Please instruct your financial advisor if you wish to change these options. |
|4. INSURANCE COMPANY ANNUITY TRANSFER (For annuity transfers in-kind, please obtain the appropriate Insurance Co. form). |
|Reference to the Delivering Firm: If this is a retirement account, a custodial owner and custodial |Signature Confirmation: I/we acknowledge that by signing this|
|beneficiary change will be processed direct at the Insurance Company. If the insurance position has |transfer form, I/we authorize the change of broker/dealer for|
|a systematic investment and/or withdrawal program running with the old custodian, then you will need |any insurance assets correlating to my/our above referenced |
|to have these programs re-established with Piper Jaffray. |brokerage account. |
|Annuity Options: |
|Liquidate IMMEDIATELY. I am aware of and acknowledge the penalty I may incur from early termination. |
| Liquidate at RENEWAL. Renewal Date: | |(Please submit 2-3 weeks before renewal date). |
| | | |
|D. CLIENT AUTHORIZATION |
|I understand that this Authorization contains Automated Client Account Transfer (ACAT) Information on page two Section E. |
|Client Signature (Participant Signature if Small Business Plan / Responsible |Date |Place Medallion Stamp Here |
|Individual Signature if Coverdell ESA) | | |
| | | |
|X | | |
|Client Signature (Trustee Signature if Small Business Plan) |Date | |
|X | | |
|Discrepancies of Account Name and Type (Optional) |
|If the account that you are transferring is in an individual's name and your Piper Jaffray account is a joint account (i.e., in more than one individual's name) |
|then each joint account holder must sign below. We hereby authorize a transfer from the individual's account named above to the joint account at Piper Jaffray. |
|Joint Client Signature / Date |Print Name |Joint Client Signature / Date |Print Name |
|X | |X | |
|Important Notice – Age 70½ restriction |To the Resigning Trustee or Custodian: Letter of Acceptance |
|If you are age 70½ or older in this year and are requesting a direct |This is to advise you that Piper Jaffray, an IRS approved custodian, will accept the |
|rollover, you must take a Required Minimum Distribution (RMD) from your |above-captioned retirement plan as successor custodian. |
|Qualified Plan prior to the direct rollover occurring. Instruct your current | |
|custodian to distribute your RMD directly to you. | |
| | |X | |
| | |Piper Jaffray as Custodian Authorized Signature | |
|• Please include a copy of the most recent statement. • If this is a NON-ACAT transfer, please sign TWO originals. • Give a copy to the client. |
|Form E0217 (9/05) |
|Piper Jaffray |ACCOUNT TRANSFER DEPARTMENT |
|800 Nicollet Mall, Suite 800, J07N04 |ACAT & NON-ACAT…….612 303-6700 |
|Minneapolis, MN 55402-7020 | |
|E. AUTOMATED CLIENT ACCOUNT TRANSFER (ACAT) INFORMATION |
|To Carrying Firm: If this account is a qualified retirement account, I have |you to liquidate the assets in my account to the extent necessary to satisfy that|
|amended the applicable plan so it names Piper Jaffray as successor custodian. |obligation. If certificates or other investments in my account are in your |
|Unless otherwise indicated, please transfer all assets in my account to Piper |physical possession, I instruct you to transfer them in good deliverable form, |
|Jaffray. I understand that to the extent any assets in my account are not readily|including affixing any necessary tax waivers, to enable the successor custodian |
|transferable, with or without penalties, such assets may not be transferred |to transfer them in its name for the purpose of sale, when and as directed by me.|
|within the time frames required by NYSE Rule 412 or similar rule of the NASD or |I understand that upon receiving a copy of this transfer instruction, you will |
|other designated examining authority. I authorize you to liquidate any |cancel all open orders for my account on your books. I affirm that I have |
|nontransferable proprietary money market fund assets that are part of my account |destroyed or returned to you credit/debit cards and/or unused checks issued to me|
|and transfer the resulting credit balance to Piper Jaffray. I authorize you to |in connection with my securities account. I understand that you will contact me |
|deduct any outstanding fees due you from the credit balance in my account. If my |with respect to the disposition of any assets in my securities account that are |
|account does not contain a credit balance, or if the credit balance in the |nontransferable. |
|account is insufficient to satisfy any outstanding fees due you, I authorize | |
|F. PIPER JAFFRAY DELIVERY INSTRUCTIONS |
|Send Checks To: |Piper Jaffray |
| |FAO: (Client Name) |
| |Acct. #: (Piper Jaffray Account Number) |
| |Attn: Account Transfer, J07N04 |
| |800 Nicollet Mall, Suite 800 |
| |Minneapolis, MN 55402-7020 |
|All Physical Equities: |Piper Jaffray |
| |Attn: Custody & Transfer, J07N08 |
| |800 Nicollet Mall, Suite 800 |
| |Minneapolis, MN 55402-7020 |
| |(REF: Client Name & Account Number) |
|Federal Wire Eligible: |(Agencies; FNMA, FHLMC (CMO), FHLB, FFCB, SLMA (MTN) US Treasuries; Notes, Bonds, Strips, Bills, Fico, Refcorp Corporates; IBRD, |
| |TVA, World Bank Notes Mortgage-Backed; FNMA, FHLMC, CMO, Pool) |
| |ABA 021000018 BK OF NYC/PIPER |
|GNMAs: |BKNYC/PPT/Piper |
|Physical Gov’t Securities: |(Commercial papers, CDs, Bank Acceptance, Physical US Treasury Coupons) |
| | |
| |Bank of New York |
| |Attn: Dorothy Willis |
| |Third Floor, Window B, Dealer Clearance |
| |1 Wall Street |
| |New York, NY 10015 |
| |(REF: Client Name & Account Number) |
|Non-DTC Eligible: |Physicals |
| | |
| |SIAC |
| |Attn: Broker Cashiering |
| |First Floor |
| |55 Water Street |
| |New York, NY 10041 |
| |A/C Piper Jaffray (#311) |
| |(REF: Client Name & Account Number) |
|Money Wires: |ABA# 091000022 |
| |U.S. Bancorp Minneapolis |
| |Minneapolis, MN |
| |A/C of Piper Jaffray #173103114547 |
| |For Further Credit To: (Client Name & Account Number) |
|DTC: |Clearing #311 |
| |(REF: Client Name & Account Number) |
|G. TRANSFERABLE ASSETS |
|Assets that CAN be Transferred In Kind |Assets that CANNOT be Transferred |Assets that MAY POSSIBLY be Transferred In Kind (Call Account |
| |In Kind |Transfer Department) |
|Corporate Securities/Stocks/Bonds |EE Savings Bonds |Annuities |
|U.S. Government Securities |Non-brokered CDs |Limited Partnerships |
|Options |Commodities |Proprietary Mutual Funds |
|Brokered CDs |Life Insurance |Precious Metals |
|Unit Investment Trusts |Real Estate |Worthless Securities |
|Foreign Stocks/Bonds | |No-Load Mutual Funds |
|Municipal Securities | | |
|Mutual Funds (with Broker/Dealer agreement) | | |
|Cash | | |
|Form E217 (9/05) |Since 1895. Member SIPC & NYSE. |
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