Third Party Limited Access Form

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THIRD PARTY LIMITED ACCESS FORM
Use this form to authorize Specialized IRA Services to disclose information about your account to a third-party. This form may also be used
to update a third-party authorization that is already in effect.
Note:
1.
You must submit a separate form for each third-party you are authorizing.
2.
This form does not allow the third-party to make any changes or direct any investments on your behalf.
This is an informational release form only.
ACCOUNT OWNER INFORMATION
Account Holder: _________________________________
Daytime Phone Number: __________________________
Account Number: ________________________________
Email Address: __________________________________
REMOVE CURRENT AUTHORIZATION
Remove all existing Authorized Individuals
Remove the following Authorized Individual only.
• Authorized Individual:________________________________________________________________
ADD A NEW AUTHORIZED THIRD PARTY
(authorized individuals cannot be minors)
The following individual will be granted limited access to your account:
Name (First/MI/Last): ___________________________________________________________________________
Street Address: ___________________________________________________________________ City: _________________________ State: ________ Zip:____________
Phone: ________- __________ - __________ Email (if granting online access):_____________________________
By my execution below, I do hereby authorize Specialized IRA Services, including all agents or employees, to disclose information related to my account to the above
named individual or company. This authorization will remain in effect until such time as I should notify Specialized IRA Services in writing to remove such account access.
By my signature below, I do indemnify and hold harmless Specialized IRA Services and any and all agents or employees with respect to this direction or the
misrepresentation of any third party to receive information regarding my account.
ACCOUNT OWNER SIGNATURE
By signing below, you:
Acknowledge that you have received a copy of this authorization form, and you state that you have
read it, you understand it, and you accept all of its terms and conditions.
Authorize Specialized IRA Services to act on all instructions given on this form.
Designate the third-party identified on this form as an authorized party, granting that individual the
ability to obtain information related to my account.
Certify that all information provided on this form is accurate to the best of your knowledge.
Account Owner’s Signature: ________________________________________ Date: ____/_____/__________
Printed Account Owner’s Signature: ______________________________________________________________
SIS REV21 2 1 F
TPAF Page 1

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