Fillable Authorization To Wire Brokerage Funds Form printable pdf download

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AUTHORIZATION TO WIRE BROKERAGE FUNDS

This form serves as a Letter of Authorization to wire cash from your Scottrade account to a bank or other financial institution.

1. SCOTTRADE ACCOUNT HOLDER INFORMATION

Scottrade Account Number

Scottrade Account Title (Name on Account)

Social Security or Tax ID Number

Telephone Number

Reason for the Request (For your account protection, please be as specific as possible.)

2. FINANCIAL INSTITUTION INFORMATION

Name of Receiving Financial Institution

Receiving Bank's ABA Routing Number / SWIFT Code

Complete Bank Address

A Scottrade representative will call you at the number provided above to verify

Is this an international wire request?

Yes -

this request. If we are unable to contact you, your wire may be delayed or

canceled. Please note that these calls will be made during U.S. business hours.

3. AMOUNT OF WIRE TRANSFER

Date to be Sent:

- OR -

All Available Cash

(domestic wires only)

4. RECIPIENT INFORMATION

Recipient's Account Title at Receiving Institution (Write out full title - "same" and "self" are not acceptable.)

Recipient's Account Number at Receiving Institution

Your Relationship to Recipient

Recipient's Street Address (no P.O. Boxes)

City

State

ZIP Plus 4

5. FOR FURTHER CREDIT TO (If Applicable)

Account Title at Receiving Institution

Account Number

Recipient's Street Address (no P.O. Boxes)

City

State

ZIP Plus 4

Please note that if you are wiring to a third party or international recipient a valid, non-expired, government issued ID must be submitted with

the request.

A $25 fee applies to domestic wire transfers and a $40 fee applies to international wire transfers. Be advised that intermediary and/or receiving

institutions may charge additional fees. For international wires, foreign exchanges rate risk may apply if the intermediary or receiving institution converts

the transfer amounts. Scottrade reserves the right to request additional verification prior to processing a wire transfer request.

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.

Signature(s) of Account Holder(s)

Account Holder's Signature

Date

Account Holder's Signature

Date

*SF3675*

Signature Verified By

SF3675/8-14