Agent Authorization/ Limited Power Of Attorney Form Page 2
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CSRIA_00778H 0416 — Page 2 of 4
1.
Account Owner information
Account Number (List all that apply. To list more than three Accounts,
use a separate sheet.)
Social Security Number or Taxpayer Identification Number (Required)
Name of Account Owner (first, middle initial, last)
Permanent Street Address (P.O. boxes are not acceptable.)
City
State
Zip Code
Telephone Number (In case we have a question about your Account.)
2.
Agent information
Note: If your Agent is a corporation or other entity, the entity must also complete and submit a CollegeBound 529 Organization
Resolution Form.
Relationship of Agent to Account Owner (Check one.)
Financial Advisor
Other
(Provide Social Security number or other Tax ID number.)
Name of Agent (first, middle initial, last)
Financial Professional Firm Name (If applicable)
CRD number provided by FINRA (if you are a financial professional)
Mailing Address
City
State
Zip Code
Telephone Number
BY SIGNING, ACCEPTING, OR ACTING UNDER THIS APPOINTMENT, I ASSUME THE FIDUCIARY AND OTHER LEGAL RESPONSIBILITIES OF AN
AGENT. I ACKNOWLEDGE THAT, AS AGENT, I ACT EXCLUSIVELY FOR THE BENEFIT OF THE ACCOUNT OWNER. I FURTHER ACKNOWLEDGE THAT I
OWE A DUTY OF LOYALTY TO AND PROTECTION OF THE BEST INTERESTS OF THE ACCOUNT OWNER, A DUTY TO AVOID CONFLICTS OF INTEREST
AND TO USE ORDINARY SKILL AND PRUDENCE IN THE EXERCISE OF THESE DUTIES. I AGREE TO DIRECT ANY BENEFITS DERIVED FROM THIS
LIMITED POWER OF ATTORNEY TO THE ACCOUNT OWNER.
SI GNAT U R E
Signature of Agent
Date (mm/dd/yyyy)
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