Limited Power Of Attorney Authorization Form - Tennessee Treasury Department
Download a blank fillable Limited Power Of Attorney Authorization Form - Tennessee Treasury Department in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Limited Power Of Attorney Authorization Form - Tennessee Treasury Department with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3ABLE
Reset Form
P.O. Box 190637
State of Tennessee
Nashville, TN 37219
Treasury Department
615-253-1833 (local)
TN
855-922-5386 (toll-free)
615-401-6816 (fax)
LIMITED POWER OF
E-mail: ABLE.TN@tn.gov
Website: AbleTN.gov
ATTORNEY AUTHORIZATION
Instruc ons
Print clearly, in all capital le ers, using blue or black ink. When requested, please color in circles completely.
Use this form to designate an individual, or en ty, including, but not limited to, a registered investment advisor,
broker/dealer, investment professional, or any other legal representa ve (“Agent”) to act as your agent with
limited authority to act on your behalf rela ve to your Achieving a Be er Life Experience (“ABLE”) account.
The powers granted are subject to Tennessee Law. Through this Limited Power of A orney Authoriza on, an
Agent may obtain informa on about and transact business within your ABLE Account as iden fi ed in Sec on
1. Based on the level of authoriza on selected, the Agent’s ability to transact within your ABLE account shall
include, but not be limited to, making investment decisions, contribu ons and withdrawals without advance
no ce to you or approval by you. You may revoke this Limited Power of A orney Authoriza on in the future by
submi ng documenta on to Tennessee’s ABLE Program (“ABLE TN”) revoking this Limited Power of A orney
Authoriza on and no fying the agent in wri ng. This Limited Power of A orney Authoriza on shall con nue
in eff ect un l it is revoked in wri ng by the Designated Benefi ciary; the Designated Benefi ciary dies; the
Designated Benefi ciary submits a new Limited Power of A orney Authoriza on; the ABLE Account is closed;
or a Court terminates the Limited Power of A orney Authoriza on. The State of Tennessee (including its
employees); the Tennessee Treasury Department (including its employees); the Tennessee State Treasurer; the
Trustees for ABLE TN cannot and do not provide legal, fi nancial, or tax advice. Please consult your a orney or
other legal, fi nancial or tax adviser with any ques ons regarding this form.
If you have any ques ons, please e-mail us at ABLE.TN@tn.gov, or call us at 615-253-1833 or toll-free at 1-855-
922-5386. ABLE TN representa ves are available to assist you Monday through Friday, 8:00 a.m. to 4:30 p.m.
(Central Time).
Submit this form, with any required documenta on, by e-mail, fax, or postal mail to the appropriate address or
phone number provided above.
1. Designated Benefi ciary Informa on
Name of Designated Benefi ciary: __________________________________________________________________
Social Security Number: _________________________________________________________________________
Account Number: ______________________________________________________________________________
Permanent Street Address: _______________________________________________________________________
Mailing Address (if diff erent): _____________________________________________________________________
City, State, and Zip Code: _________________________________________________________________________
Telephone Number: _____________________________
Alternate Telephone Number: ___________________
TR-0469
- 1 -
RDA-11176
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form 3840 - Limited Power Of Attorney Authorization For Disclosure Of Information For Tax Clearance Purposes Only
Financial
Form 4300 - Limited Power Of Attorney Borrower's Authorization For Disclosure Of Information
Financial
Related Categories
Parent category: Legal