Financial Accounts Form

FINANCIAL ACCOUNTS FORM

Use this form to report and authorize use of financial accounts for transfers, holdings, reporting, and record-keeping. Complete all applicable sections, sign and date at the end, and attach required supporting documentation where indicated. The information provided will be relied upon for account setup, transfer authorization, and regulatory reporting.

1. Client Information

Individual Joint Account Corporation Partnership Trust / Fiduciary Other

2. Account Details (List up to four accounts)

Account 1

Account 2 (if applicable)

If additional accounts exist, attach a separate page with the same fields and mark "Supplemental Account List" at the top of each additional page.

3. Authorization and Access

By signing this form the Client authorizes the firm, its agents, and designated service providers to (a) obtain account information and statements from the listed financial institutions, (b) initiate transfers, credits and debits to and from the listed accounts in accordance with separate transfer instructions, and (c) disclose account information to third parties where required to effect transfers or to comply with legal obligations. Authorization granted is limited to the accounts and purposes identified herein unless otherwise documented in a separate written agreement.

Check applicable authorizations:

Authorize electronic transfers to/from listed accounts
Authorize receipt of statements and confirmations from institutions
Authorize disclosure to third-party service providers as necessary
Authorize stop-payment on debits initiated by the signing party (subject to institution rules)

4. Supporting Documentation

Provide one copy of each item required for verification. Retain originals; copies will be accepted for processing where permitted.

Voided check for each checking account
Recent bank statement (within 90 days)
Letter of authorization on institution letterhead (if required)
Trust or corporate formation documents (if applicable)

5. Representations, Warranties and Indemnity

The Client represents and warrants that the information provided on this form and any attachments is true, complete and accurate. The Client warrants that it has full authority to provide the account information and to authorize the transactions and disclosures described herein. The Client agrees to indemnify and hold harmless the firm, its affiliates and agents from any loss, claim or liability (including reasonable attorneys' fees) arising from reliance on the information provided, from the Client's breach of any representation or warranty, or from unauthorized use arising from Client's failure to notify the firm promptly of changes to account ownership or status.

The Client acknowledges that financial institutions may impose their own rules and fees for transfers, and that the firm is not responsible for institution-imposed fees. The Client agrees to notify the firm in writing of any change in account information, authority, or ownership within a reasonable period not to exceed 10 business days after such change.

6. Privacy and Use of Information

Information provided will be used to process account instructions, to fulfill regulatory and compliance obligations, and to maintain accurate records for account administration. The firm will exercise reasonable care to protect confidential information but may disclose information as required by law, regulation, subpoena or to effect account services. The Client consents to such disclosures as necessary and authorized by this form.

7. Additional Instructions

8. Certification

I certify, under penalty of law, that I am authorized to provide the information contained in this Financial Accounts Form and that the information is complete and accurate to the best of my knowledge. I consent to the use of this information to effect transfers and account administration, and I agree to the representations, warranties, indemnities and authorizations contained in this form. I acknowledge that misrepresentation or omission of material facts may result in denial of services or other remedies available at law.

Printed Name:

Title (if signing on behalf of entity):

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