Third Party Trading Form For Td Ameritrade Self-Directed Brokerage Accounts
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1
2Third Party Trading Form for TD Ameritrade
83831111
Self-Directed Brokerage Accounts
Colorado Public Employees’ Retirement Association
PO Box 5800 Denver, Colorado 80217-5800
303-832-9550
1-800-759-PERA (7372)
Fax: 303-863-3727
Use this form for the PERAPlus 401(k), PERAPlus 457, and the PERA DC Plan. Please complete this form and return it directly to
Colorado PERA at the address above.
Apply third party trading information to (check all that apply): q PERAPlus 401(k)
q PERAPlus 457
q PERA DC Plan
SSN
TD Ameritrade Account Number _____________________________________________
Participant Name ________________________________________________________________________________________________________
Last
First
Middle
Mailing Address __________________________________________________________________________________________________________
Street
City
State
ZIP Code
(
)
Phone number _________________________
Authorized Agent Designation
Full Legal Name ____________________________________________________________________________________________________
Last
First
Middle
Date of Birth
⁄
⁄
Social Security Number
__________
_ _________
_ _________
____________________________________________
Address __________________________________________________________________________________________________________
Street
City
State
ZIP Code
Employer Name ___________________________________________
Type of Business ________________________________________
Employer Address __________________________________________________________________________________________________
Street
City
State
ZIP Code
If there are additional authorized agents, please attach another copy of this form and fill out the above for each authorized agent. Please read the
information below and sign on the reverse.
Disclaimer and Role of Colorado PERA
The Plan participant and authorized agent(s) acknowledge and agree that:
The Plan participant has appointed and authorized the authorized agent(s) designated above to give instructions to
TD Ameritrade regarding the Plan participant’s Self-Directed Brokerage Account (SDBA) and the Plan participant and
authorized agent(s) have executed and/or will execute any and all forms required by TD Ameritrade.
Colorado PERA has not approved, recommended, or endorsed the authorized agent(s) and the authorized agent(s) is not
affiliated, controlled by, or employed by Colorado PERA.
Colorado PERA has no duty to supervise or monitor any of the authorized agent(s) activities regarding the SDBA.
Colorado PERA has no responsibility for the selection of the authorized agent(s), the maintaining of the authorized agent(s)
on the SDBA, any and all rights and authorizations granted to the authorized agent(s) or the revocation of such rights and
authorizations, and/or any acts or omissions by the authorized agent(s) in connection with the SDBA.
(continued on reverse)
8/383-TDTRADE (REV 11-11)
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