Durable Power Of Attorney - New York (Page 6 of 10) in pdf

6. Attorney-in-Fact, continued

Associations and Corporate Control Status

Fidelity is required by industry regulations to determine if you or someone in your household are

associated with a financial services company or are a control person of a corporation.

If you check this box,

You are associated with or employed by a stock exchange, exchange

attach compliance officer’s

member, FINRA, or municipal securities dealer:

letter of approval (“407

Same as employer

letter”). If your association

is with your employer

Entity Name

Entity Address

we must let them know

that you have applied for

this account. Having an

City

State/Province

Zip/Postal Code

Country

account at a firm does not

make you an associate.

You are, or someone in your household or immediate family is, a control

person of a publicly traded company under SEC Rule 144 (such as director,

10% shareholder, policy-making officer, or member of the board of directors).

Company Name

Trading Symbol

7. Attorney-in-Fact Signature and Date

Named Attorney-in-Fact must sign and date.

By signing below, you:

you and upon written request, to provide

the name and address of the credit report-

• Affirm that you have read, and that you

ing agency used.

understand and agree to be bound by, the

provisions of this form as well as the terms

• Agree that if you have not checked the box

and conditions set forth in the Fidelity

for affiliations, you represent and warrant

Account Customer Agreement (including

that you are not affiliated with or employed

those terms to which the account owner is

by a stock exchange or a broker-dealer or

you are not a control person or affiliate or a

bound) and any applicable state notices.

public company under SEC Rule 144 (such

• Affirm that you are the Attorney-in-Fact

as a director, 10% shareholder, or a policy-

named in Section 6.

making officer), or an immediate family or

• Accept appointment as Attorney-in-Fact

household member of such a person.

for the owner identified in Section 1,

• Affirm that the account owner is not

according to all terms and conditions

deceased, has not partially or totally

described in this form.

revoked, suspended, or terminated the

• Agree that any information given on

authority delegated and that there is no

this Durable Power of Attorney is sub-

petition pending to determine the inca-

ject to verification. You authorize Fidelity

pacity or to appoint a guardian for the

Brokerage Services LLC, National Financial

account owner.

Services LLC and their agents, affiliates,

• Agree not to issue or relay any instructions

assigns, control persons, employees, suc-

that you believe to be inconsistent with

cessor custodians, officers and directors

your powers or responsibilities as Attorney-

(collectively, “Fidelity”) to act on all instruc-

in-Fact.

tions given on this form, to obtain a credit

or other financial responsibility report on

Attorney-in-Fact Signature and Date continues on next page.

1.933269.101

027750106

Page 6 of 10

Durable Power Of Attorney - New York Page 6

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