Account Transfer Form

ACCOUNT TRANSFER FORM

WHEREAS

WHEREAS, Transferor: is the recorded owner of the account and assets described below, and desires to transfer such account and assets to Transferee; and

WHEREAS, Transferee: agrees to accept the transferred account and assets subject to the terms and authorizations set forth in this form; and

WHEREAS, Current Custodian: and Receiving Institution: will effect the transfer in accordance with industry practice and applicable law.

TRANSFER DETAILS

SCOPE OF TRANSFER

Transfer method (check all that apply): ACAT (Automated Customer Account Transfer) Transfer in kind Liquidate and transfer cash IRA rollover Wire transfer

Estimated aggregate value of assets to be transferred: $

Special handling instructions (if any):

AUTHORIZATION AND REPRESENTATIONS

Transferor represents and warrants that Transferor is the lawful owner of the assets listed above, that the assets are free of liens and encumbrances except as disclosed, and that Transferor has full authority to direct this transfer. Transferor authorizes the Current Custodian to release and deliver the assets to the Receiving Institution as instructed herein.

Transferee accepts the transfer subject to review and standard receiving procedures. Receiving Institution may place reasonable holds or restrictions as required by law or internal policy and will notify Transferor of any rejection or inability to accept particular assets.

Check one: Transfer in kind only Liquidate remaining positions and transfer cash Partial transfer (specify in Assets and Instructions)

PAYMENT TERMS

Transfer fee amount: $ . Fee(s) are assessed in accordance with institutional schedule and are due upon billing.

Fee billed to: Transferor Transferee

Payment schedule or special billing instructions:

Late fee for unpaid transfer-related charges:

TERM AND TERMINATION

This authorization is effective as of Effective Date: and shall remain in effect until completion of the transfer or earlier termination as provided below.

Either party may terminate this authorization by giving written notice to the other party and to the relevant institution not less than days prior to the intended termination date. Termination does not affect obligations incurred prior to the termination date.

CONFIDENTIALITY

Each party agrees to maintain as confidential all nonpublic information received from the other party in connection with this transfer and to use such information only to effect the transfer, except as required by law, court order, or regulatory authority. Reasonable disclosures to advisors and service providers are permitted provided they are bound to confidentiality obligations at least as restrictive as those herein.

GOVERNING LAW

This Account Transfer Form shall be governed by and construed in accordance with the laws of the state where the Receiving Institution maintains its principal place of business, without regard to conflict of law principles.

ENTIRE AGREEMENT

This form, together with any attachments and institution-specific transfer agreements acknowledged by the parties, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior oral or written agreements and understandings.

INDEMNIFICATION

Each party shall indemnify and hold harmless the other party and any involved institutions from and against any losses, liabilities, costs, or expenses (including reasonable attorneys' fees) arising from any misrepresentation, breach of warranty, or failure to perform obligations under this authorization, except to the extent such loss arises from the indemnified party's own gross negligence or willful misconduct.

CERTIFICATIONS

By signing below, Transferor certifies under penalty of perjury that the information provided is true, correct, and complete, and that Transferor has the requisite authority to effect the transfer. Transferee acknowledges acceptance of the transfer subject to the terms and conditions stated herein and institution-specific requirements.

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