WellsTrade Direct Registration System Stock Transfer Request (To ...

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WellsTrade? Direct Registration System

Stock Transfer Request (To Transfer stock held with Transfer Agent)

Account Number (Client to complete-Required)

Sub Firm # 205

Account Number

(Office Use Only)

Use this form to authorize Wells Fargo Advisors ("WFA") to transfer your securities, currently registered in certificateless form with the transfer agent (via DTC Direct Registration System "DRS"), to your WFA account.

Account Information

Name of Stock

CUSIP (9 digits)

Symbol

Account Number with Agent (Include all dashes or spaces)

Number of Whole Shares to be Transferred

Tax IDs on File with Agent - (Please confirm the number with the Agent. It may be different from what is on file in joint or trust accounts).

Primary Tax ID

Secondary Tax ID

DRS Instructions: Deposit

Agent Name

SSN or Tax ID Agent Account Number (use N/A if no account number)

Registration: (use agent registration for deposits and new owner registration for withdrawals

Address

City

State

Zip

Select from one of the following instructions to WFA:

Transfer all Whole Shares and have Agent Sell Fractions (A) Transfer all Whole Shares--Keep Fractions with Agent (P) Transfer all Whole Shares, have Agent Sell Fractions and Close Account with Agent (T) Move Specified Number of Whole Shares (no fractions). Number of Whole Shares to be Transferred:

Note: Agent will mail proceeds from the sale of fractions directly to Client. Please obtain and include a monthly statement dated within the past 90 days.

Authorization

I/We hereby authorize Wells Fargo Advisors, LLC ("WFA") to request the transfer agent/issuer to transfer the above listed stocks to my/our above-listed WFA account. I/We understand that a transfer from an individual account to an account with joint registration may change my/our ownership rights and may change the primary Social Security or tax ID number on the account. I/We also understand that the transfer may change the account registration and beneficiary designation(s). I/We will consult with our legal or tax advisor regarding our personal situation.

By signing below, I/we understand and accept any change of registration and ownership and agree to hold WFA and the delivering agent harmless from acting on these instructions, including any and all claims, liabilities, damages, taxes and actions (including attorney fees) resulting from compliance with this request.

Client Signature

Client Signature

X

Client Signature

X

Name of Trust (if applicable)

Print Name Print Name

Date Date

Trustee Signature

X

Print Name

Date

Please include a statement dated within the past 90 days. Shares will transfer into your WFA account within 3 to 5 business days of WFA receiving your request.

WellsTrade? - Submit your completed form to: Wells Fargo Advisors, PO Box 66535, St. Louis, MO 63166-9954, or Fax to 800-433-0738 Should you require assistance with this form, please call 1-800-TRADERS (1-800-872-3377).

Investment and Insurance Products: Not Insured by FDIC or any Federal Government Agency May Lose Value Not a Deposit of or Guaranteed by a Bank or Any Bank Affiliate

Wells Fargo Advisors, LLC is a registered broker-dealer and separate non-bank affiliate of Wells Fargo & Company

587495 (Rev 03 ? 02/13)

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