Securities Custody Authorization Letter Form

Full Legal Name of Account Owner / Requester

First NameMiddle NameLast Name

Mailing Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Brokerage / Custody Institution Name

Securities Account Reference (Masked or Internal Reference Only)

Authorized custodian / agent name or organization

Relationship to account owner

Scope of authorization

Effective date

Date

Date range end

Date

Limitations or special instructions

I confirm the information provided is accurate and authorize the custody arrangement described

Account Owner / Requester Signature

Date Signed

Date