Financial Change of Adviser

FINANCIAL CHANGE OF ADVISER

Client Name:    Account Number:

Client Information

Account Type: Individual Joint Trust Corporate IRA

Current Adviser Information

Adviser Rep/CRD Number:    Phone:

New Adviser Information

Adviser Rep/CRD Number:    Branch Address:

Contact Phone:    Email:

Requested Effective Date:

Authorization and Acknowledgements

By executing this Financial Change of Adviser form, Client Name authorizes the custodian and current adviser to release account information and to transfer authority to New Adviser named above. Client expressly appoints the new adviser as authorized representative to provide investment recommendations and, where applicable, to exercise discretionary authority in accordance with any separate investment management agreement executed between Client and New Adviser.

Client revokes any prior adviser appointment only to the extent necessary to effect the change requested herein. This authorization does not terminate any standing transfer instructions or account agreements with the custodian unless expressly stated in writing below.

Client represents and warrants that the information provided on this form is true, that Client has authority to request changes to the account, and that Client will provide any required documentation to validate authority if requested. Client further agrees to indemnify and hold harmless the custodian and current adviser from any claims, liabilities or losses arising from the implementation of this change so long as actions are taken in good faith reliance upon the terms of this authorization.

Fee Arrangements and Billing Instructions

The client authorizes the following fee arrangement with the new adviser (select all that apply):

Advisory fee as percentage of assets under management Flat periodic fee Commission-based arrangement

Client authorizes deduction of advisory fees from account assets where permitted: Yes No

Account Instructions and Restrictions

Representations and Signature

I certify that I am authorized to make changes to the account listed above. I understand that the custodian and broker-dealer may rely on this instruction and may require additional documentation. I further certify under penalty of perjury that the taxpayer identification information associated with this account is correct as provided to the custodian.

Processing Notice: Submission of this form authorizes the custodian to change the adviser of record as set forth. The custodian and any intermediary firms reserve the right to request any additional documentation or to reject this request where required by internal policy or regulation. Implementation of fee changes or new billing arrangements may be subject to separate agreement and fee authorization.

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