Form 27 - Durable Power Of Attorney Form And Indemnity Page 2
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3FORM 27 09/15
DURABLE POWER OF ATTORNEY AND INDEMNITY
ABA Retirement Funds Program (the “Program”)
Customer Contact Center: 800.348.2272
P.O. Box 5142 • Boston, MA 02206-5142
Website:
Complete this form to authorize power of attorney for transactions of the participant’s account. The participant completes sections 1 and 2;
then reads, completes and signs section 3. A Notary Public completes and signs section 4. The Attorney-In-Fact and Notary Public complete
and sign section 5.
1. EMPLOYER INFORMATION
Program Plan Number: ___ ___ ___ ___ ___ ___ Employer Tax ID Number: ___ ___ – ___ ___ ___ ___ ___ ___ ___ IRS Plan Number: ___ ___ ___
Employer’s Name: ______________________________________________ Employer’s Business Phone Number: (
)
–
2. PARTICIPANT INFORMATION
Participant’s Name: ______________________________________________ Social Security Number: ___ ___ ___–___ ___–___ ___ ___ ___
Date of Birth: ___ ___ /___ ___ /___ ___ ___ ___
Sex:
M
F
Marital Status:
Single
Married
Participant’s Primary Residence:
Street Address: __________________________________________________________________________________________________________
(MAXIMUM OF 30
____________________________________________________________________________________________________
CHARACTERS EACH LINE)
City:______________________________________________________ State: ________________________ Zip Code: __________________
Plan: ____________________________________________________
Business Phone Number: (
)
–
3. PARTICIPANT AUTHORIZATION
I, _____________________________________________, of __________________________________________ do hereby make, constitute and
(CITY, STATE)
appoint _________________________________________, whose address is _______________________________________________________
________________________________________________________________________________________________________________________
and whose specimen signature is _________________________________________________ my true and lawful attorney or agent (“Agent”)
for me and in my name, place and stead (1) to transmit to the trustee, Mercer Trust Company ("MTC") either orally or in writing in
accordance with procedures established by MTC from time to time, instructions for the purchase, sale, transfer or distribution of units
of the ABA Members/MTC Collective Trust (“Collective Trust”) or any other investment options available under the Program; (2) to enter
into any other lawful transaction with respect to my participant account (“Account”) in the Program.
I hereby agree to indemnify and hold MTC harmless from acting upon instructions, either oral or in writing, believed to have originated from
said Agent and from any and all acts of said Agent with respect to my Account.
This authorization and indemnity is a continuing one and shall remain in full force and effect and shall be binding upon the undersigned’s
heirs, executors, successors, beneficiaries or assigns until revoked by the undersigned by a written notice delivered to the address shown
above. Such revocation shall become effective as soon as MTC has had a reasonable amount of time to act upon it. The revocation shall not
effect any liability in any way resulting from transactions initiated prior to MTC’s acting on such revocation within a reasonable amount of
time. In case of the death, disability or incompetence of the undersigned, this authorization shall continue and MTC and the Program shall
not be responsible for any action taken on the basis of this authorization until MTC has received written notice thereof addressed to the
Program at the above address.
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