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Transfer On Death Distribution Form

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TRANSFER ON DEATH DISTRIBUTION

BENEFICIARY INFORMATION

am a designated beneficiary for

Print Name

account

registered to

Scottrade Account #

Print Decedent’s Name

My Social Security number is

My Scottrade account number is

Beneficiary Account #

In accordance with the Transfer on Death Beneficiary Plan Agreement (“TOD Agreement”), I am providing this notarized

distribution form and a copy of the death certificate. In addition, if I do not have an existing account, I have completed a

Scottrade Brokerage Account Application to open a new account. I request that Scottrade transfer the percent of assets

indicated in the above TOD Agreement to my Scottrade account, listed above.I understand that in the event that any

securities in the account cannot, for any reason, be partitioned and transferred to the beneficiaries equally, Scottrade

reserves the right, to the extent necessary, to liquidate the securities and transfer the proceeds of that sale among the

beneficiaries according to the percentages indicated. I understand that Scottrade also reserves the right to take no action

with regard to distribution until there are clear instructions from each beneficiary or a court of competent jurisdiction.

DATE

BENEFICIARY SIGNATURE

Notary:

State of: ______________________________________

County of: _____________________________________

On the _______ day of _____________________, 20 ______, before me, the undersigned notary public,

personally appeared ___________________________________, known to me to be the person(s) whose

name(s) is/are subscribed to the within instrument and acknowledged that he/she/they executed the same

for the purposes therein contained. In witness whereof, I hereunto set my hand and official seal.

Notary Public

*SF1027*

SF1027/7-14

Transfer On Death Distribution Form

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