Specific Power Of Attorney For Multiple Security Owners Form printable pdf download

FORM COMPLETION GUIDE

Specific Power of Attorney for Multiple Security Owners

Section I. Registered Owner

DISTANT OWNER

I ___________________________________________________ hereby attest that I am a registered owner

(Registered owner – please print)

the security listed below and am unable to be physically present to apply my signature and to have my

endorsement Medallion Signature Guaranteed to effect the transfer indicated in Section IV.

Section II. Power of Attorney Authorization

LOCAL OWNER GUARANTOR CUSTOMER

I also certify that __________________________________________________________________________

(Name of co-owner)

is a co-owner of the security listed below, and authorize this person to act as power of attorney on my behalf

for the specific reason listed in Section IV.

Section III. Security Identification

Note: As evidence of ownership, a copy of the certificate face or a recent account statement from the

Issuer is required.

NAME OF BOND, STOCK OR MUTUAL FUND

Name of Security: _________________________________________________________________________

(IF BOND/STOCK CERT.)

(IF MUTUAL FUND)

CUSIP Number: _________________________ Mutual Fund Acct. Number: _________________________

(If available)

(IF BOND/STOCK

BOND - ENTER

Certificate Number(s): __________________ Number of (shares/units/principal amount): ________________

CERT.)

PRINCIPAL AMT.

STOCK - ENTER

Section IV. Transaction Type

# OF SHARES

FILL IN APPLICABLE TRANSACTION

(a) Transfer of Ownership

(b) Redemption/Sale/Liquidation

MUTUAL FUND -

ENTER AMOUNT

(c)

Other (please specify): _________________________________________________________________

Section V. Signature of Registered Owner (Section I.)

DISTANT OWNER

Signature of Registered Owner: ________________________________________ Date: ________________

OF DISTANT OWNER

Tax Identification Number: __________________________________________________________________

OF DISTANT OWNER

Address: ________________________________________________________________________________

Phone Number: ___________________________________________________________________________

OF DISTANT OWNER

Section VI. Medallion Signature Guarantee

DISTANT GUARANTOR MEDALLION

Affix Medallion Guarantee in this space

Note: This specific Power of Attorney is designed to facilitate the transfer, redemption, sale, or liquidation of a security that is

held by multiple registered owners when all owners cannot be present to provide their signature(s) and secure a Medallion

Signature Guarantee. Users should consult state law for specific requirements that may apply to powers of attorney.

Specific Power Of Attorney For Multiple Security Owners Form

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