Fillable Authorization & Third Party Release To Deposit Certificates

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AUTHORIZATION AND THIRD-PARTY RELEASE TO DEPOSIT CERTIFICATE(S)

Use this form for certificate deposits resulting in a partial change of ownership, such as the deposit of an individually registered certificate into that person's joint

brokerage account. For third-party deposits (the certificate owner is not registered on the account), the depositor must establish a like-titled Scottrade

account, then

submit an Authorization to Transfer Cash/Securities form.

SECURITIES INFORMATION

Quantity

Security Name

Symbol

CUSIP

Quantity

Security Name

Symbol

CUSIP

Quantity

Security Name

Symbol

CUSIP

Quantity

Security Name

Symbol

CUSIP

REGISTRANTS ON CERTIFICATES

Name

Date of Birth

Social Security Number (Required)

Scottrade Account # (if applicable)

Street Address (Required)

City, State, ZIP (Required)

Name

Date of Birth

Social Security Number (Required)

Scottrade Account # (if applicable)

Street Address (Required)

City, State, ZIP (Required)

REGISTRANT SIGNATURES

All individuals listed on the certificate must sign.

I authorize the deposit of the above certificate(s) into the receiving account listed below and I understand

that by making this deposit I am relinquishing ownership of said securities.

Signature

Date

RECEIVING ACCOUNT INFORMATION

Scottrade Account Title

Scottrade Account Number

Relationship to Third Party

Reason for Request

COST BASIS

If the securities you are transferring are part of a larger position that was purchased in multiple tax lots, the default method for determining which shares to transfer is First-In, First-Out

(FIFO), unless you have previously specified a different global tax strategy that will implement another method. To specify the transfer of alternate shares, complete the section below.

Symbol

Number of Shares

Acquired Date

Average Unit Cost

Symbol

Number of Shares

Acquired Date

Average Unit Cost

If applicable, indicate transaction type:

Inheritance

Gift

I hereby agree to indemnify Scottrade, its affiliates, successors, assigns, officers, directors, agents, and employees, and hold them free and harmless from, and to promptly pay Scottrade upon

demand for, any and all losses, liabilities, claims, damages, and costs (including reasonable attorney fees) or financial obligations that may arise as a result of Scottrade’s reliance on the information

provided in this document, and from acting upon instructions believed by Scottrade to have originated with me. This indemnity is in addition to, and no way limits or restricts any rights or

responsibilities that have been made under any other agreement or agreements between me and Scottrade.

All individuals listed on the Scottrade

account must sign.

Account Holder's Signature

Date

Account Holder's Signature

Date

*CC4503*

Signature Page

Signature Verification via

Application

Associate Initials