2011 Expense Payment Form Page 2

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4. Payment Instructions
Select one method (Please refer to your current Fee Schedule for applicable fees. You must pay qualified investing fees
with cash from your account).
A.
Wire (fee applies) Bank name: _______________________________________________________________________________
ABA #/routing #: __________________________________________ Bank account #: ___________________________________
Other Instructions: ___________________________________________________ Bank phone #: (______) _______ - ______________
Overnight signed documents to the payee (fee applies)
---------------------------------------------------------------------------------------------------------------------------------------
B.
ACH (Please make sure the receiving bank can support ACH)
Bank Name: ____________________________________
ABA #/routing #: __________________________________________ Bank account #: ___________________________________
Other Instructions: ___________________________________________________ Bank phone #: (______) _______ - ______________
Overnight signed documents to the payee (fee applies)
---------------------------------------------------------------------------------------------------------------------------------------
C.
Check
Please mail to the payee address in Section 2
Mail check to other: ___________________________________________________________________________________________
Address: _________________________________________________________________________________________________________
City: _________________________________________________ State:_________ Postal Code: ___________ - __________
Overnight signed documents to the payee (fee applies)
5. Authorization
The person signing this form must be an authorized party for the account on file with PENSCO.
I agree to release, indemnify, defend, and hold PENSCO harmless for any claims arising out of this payment. This includes, but is
not limited to, claims that this payment is not prudent, proper, legal, or diversified. I also understand and agree PENSCO will not be
responsible to take any action should the investment noted herein become subject to default, including fraud, insolvency, bankruptcy,
or other court order or legal process. This payment is further subject to all terms and conditions of the accountholder’s Custodial
Agreement within PENSCO and all applicable State and Federal laws.
Authorized By: _____________________________________________________________________________________________________________
(Printed name of authorizing party)
________________________________________________________________________________________________ _______________________
Authorized Party Signature (Required)
Date
Phone: 800-962-4238
Send mail to:
For express deliveries:
Fax to: 303-614-7032
PENSCO Trust Company
PENSCO Trust Company
P.O. Box 173859
717 17th Street, Suite 2200
Denver, CO 80217-3859
Denver, CO 80202-3308
PENSCO does not provide investment advice, does not sell investments, and does not offer tax or legal advice.
PENSCO does not evaluate, recommend or endorse any advisory firm or investment. Investments are not FDIC insured
and are subject to risk, including the loss of principal.
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Confidential once completed.
Expense Payment Instructions IRA-5201 (11/06/12)

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