Fillable Deposit/withdrawal At Custodian - Outgoing Form printable pdf download

Deposit/withdrawal At Custodian - Outgoing Form

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DEPOSIT/WITHDRAWAL AT CUSTODIAN - OUTGOING

Scottrade Account Holder Information

Account Title

Account Number

Social Security Number or Tax ID Number

Stock Information

Number of Shares

CUSIP Number

Symbol

Company Name

Reference or Transaction Number

Registration (Complete if Requesting a Certificate)

Mailing Address (complete physical address, No P.O. Box)

Transfer Agent Name

COST BASIS

If the securities you are transferring are part of a larger position that was purchased in multiple tax lots, the default method for determining which shares to transfer is First-In, First-Out

(FIFO), unless you have previously specified a different global tax strategy that will implement another method. To specify the transfer of alternate shares, complete the section below.

Symbol Number of Shares Acquired Date Average Unit Cost

Symbol

Number of Shares Acquired Date Average Unit Cost

If applicable, Indicate transaction type:

Inheritance

Gift

I give Scottrade, Inc. permission to electronically transfer the above-security from my account at Scottrade to the transfer agent. I

acknowledge that a separate account at the transfer agent may be set up to receieve this transfer.

Please contact the transfer agent to give them instructions on transferring or receiving shares to or from

Scottrade. Our DTCC participant number is 0705.

Account Holder's Signature

Date