Third-Party Release Form

Third-Party Release Form
This form is used to transfer ownership of a certificate(s) and deposit it into the brokerage account.
(Note that you cannot deposit trust-registered certificates, limited shares, or penny stocks into a third-party account.)
IA Firm Name*
IA Master Account*
Account Holder
Account Number*
Account Registration*
Registered Owner(s)/Agent(s)
A separate form must be completed for each registered owner/agent of the certificate(s).
Depending on the ownership mentioned on the certificate registration, fill out either A or B.
A. Owners of Non-Entity-Registered Entities
(Individual, Joint Tenants, Tenants in Common, etc.)
Registered name of the certificate(s) is/are Name(s)* , request that the deposit Number of share (Face value)* of Name of the company* into the above-mentioned account.
B. Entity-Registered Owners
(Corporation, Estate, LLC/LLP, etc.) For entity-registered ownership, further supporting documentation may be necessary.)
I, Name* certify that I am a lawfully authorized agent and that I am allowed to sign this Third-Party Release Form on behalf of Number of share (Face value)* and ask that you make a deposit Number* of Name of the company* into the above-mentioned account.
Are you a firm director, a 10% shareholder, or a policy-making officer?*
YesNo
What kind of relationship do you have with the accountholders?*
Why are you giving up control of this certificate?*
DOB*
MonthDayYear
Date
Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Certificate Owner's or Agent's Signature*
Clear
Date Signed*
MonthDayYear
Date
Certificate of Notary Public Acknowledgement
State/ Country*
The above-named individual(s) personally appeared before me and proved to me, on the basis of satisfactory evidence, that he/she/they are the person(s) whose name(s) is/are subscribed to the within instrument, and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that the person(s), or the entity on whose behalf the person(s) acted, executed the instrument by his/her/t
I certify that the above text is truthful and correct under penalty of perjury.
Notary Signature*
Clear
Notary Seal*
Clear
Today's Date*
MonthDayYear
Date
My commission is set to expire on the following date:*
MonthDayYear
Date
Should be Empty:

Third-Party Release Form

Account Holder

Registered Owner(s)/Agent(s)

A. Owners of Non-Entity-Registered Entities

B. Entity-Registered Owners

Certificate of Notary Public Acknowledgement