Funds Custody Authorization Form
Authorize a third party to hold and manage your funds. Please complete all required non-sensitive details.
Account Holder's Full Name
*
First Name
Last Name
Account Holder's Email Address
*
example@example.com
Account Holder's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Authorized Third Party's Full Name
*
First Name
Last Name
Relationship to Account Holder
*
Please Select
Family Member
Business Partner
Financial Advisor
Attorney
Other
Scope and Purpose of Authorization
*
Effective Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Authorization Expiry Date (if applicable)
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Account Holder's Signature
*
Submit Authorization
Submit Authorization
Should be Empty: