Reset Form BROKERAGE ACCOUNT APPLICATION Select an Account: Joint - type: Partnership - type: Custodial Individual Trust Estate Print Form IRA - type: Corporate - type: Qualified Plan - type: Conservator/Guardianship Applicant Information about the primary account holder - depending on the account type, this may be the minor, protected person, or organization (trust, corporation, partnership, etc.). Name of Individual/Organization - if an individual, list first, middle & last names Mr. Mrs. Ms. Primary Physical Address no P.O. boxes or mail receiving/incorporation services State City ZIP plus 4 Coverdell ESA Investment Club Update Acct #: Non-Corporate Org Co-Applicant Information about the secondary account holder - depending on the account type, this may be a custodian, trustee, trading officer/partner, or other authorized representative. Name First Mr. Mrs. Ms. Middle Last Primary Physical Address no P.O. boxes or mail receiving/incorporation services State City (legal residence) Account Mailing Address How did you hear about us? Internet TV/Radio Ad Print Ad News Article Already a Client Refer/Promo Code: ZIP plus 4 (legal residence) if different from home address; P.O. boxes may be used Account Email Address Phone Home check preferred Cell Social Security/Tax ID # Date of Birth Citizenship Information Phone Work check preferred Are you a U.S. citizen? No - complete next section Yes - skip to employment Country of citizenship: Are you a permanent U.S. resident? Home Cell Work Social Security/Tax ID # Date of Birth Are you a U.S. citizen? No - complete next section Yes - skip to employment Citizenship Information Country of citizenship: Are you a permanent U.S. resident? Yes - Alien Registration Number: No*- Visa type: Yes - Alien Registration Number: No*- Visa type: *If you will be in the U.S. 183 days or less, contact our International Department for assistance. *If you will be in the U.S. 183 days or less, contact our International Department for assistance. Employment Employed - list occupation: Unemployed Self-employed Employment Homemaker Student Employed - list occupation: Unemployed Self-employed Retired Employer Employer Employer Address Employer Address list occupation if self-employed Homemaker Student Retired list occupation if self-employed Yes No Is any applicant employed by or affiliated with a securities firm, a securities exchange, or FINRA? Yes No Is any applicant a control person or affiliate of a public company as defined by the SEC? This would generally include If yes, provide organization name and compliance department address: 10% shareholders, members of the Board of Directors, and policy-making officers. If yes, provide company's trading symbol and name: Yes No Is any applicant, member of immediate family, or business associate a senior foreign political official? Is this an Online Trading Account? Yes - Trade confirmations and monthly account statements are posted electronically. To receive paper copies, log into your account and access the "My Account" tab to change your document delivery settings (fees may apply). Mail or Hold No - Non-Internet commissions apply. Trade confirmations and monthly account statements are mailed free of charge. Sales Proceeds: Mail or Dividends & Interest: Hold Margin - sign Margin section below. Not available for IRAs, Custodial accounts, Coverdell ESAs, Conservatorships, Guardianships or Estate accounts. Additional Services Options - complete an Options Application** check all that apply Account Transfer: complete an Account Transfer Form** **Go to the Scottrade.com Forms Center, or contact us to have the form sent to you. Under penalties of perjury, I certify that: 1) The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me). 2) I am not subject to backup withholding because: (a) I am exempt from backup withholding, (b) I have not been notified by the IRS that I am subject to backup withholding as a result of failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding. If you are subject to backup withholding, cross out item 2. The IRS does not require your consent to any provision of this document other than the certification required to avoid backup withholding. 3) I am a U.S. person (including a U.S. resident alien). By signing this Application, I acknowledge that I have received, read and agree to abide by the terms of the accompanying Brokerage Account Agreement, which contains a pre-dispute arbitration clause on page 11, item VII-B. X Applicant/Authorized Person's Signature Date X Co-Applicant/Authorized Person's Signature Date Margin - sign below ONLY if you are applying for margin privileges *SF1000* SF1000/12-12 By signing this Application I acknowledge that I have received, read and agree to abide by the terms of the accompanying Brokerage Account Agreement, including the Margin Accounts provisions starting on page 8. X X Applicant/Authorized Person's Signature Date Co-Applicant/Authorized Person's Signature Date Page 1 of 2 For SAS Use Only Registered Principal *SF2362* SF2362/6-11 ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ – ___ ___ P.O. Box 31759, St. Louis, MO 63131-0759 ROTH INDIVIDUAL RETIREMENT ACCOUNT ROTH IRA HOLDER’S NAME AND ADDRESS #6100 (1/2009) ROTH IRA CUSTODIAN’S NAME, ADDRESS AND PHONE Scottrade, Inc. P.O. Box 31759 St. Louis, MO 63131-0759 Social Security Number Date of Birth Roth IRA Account Identification Home Phone Contribution Date Business Phone Contribution Amount Contribution For Tax Year Contribution Type Regular Transfer (from Roth IRA) Conversion Rollover (from Roth IRA) Recharacterization Rollover from eligible retirement plan DESIGNATION OF BENEFICIARY(ies) If neither primary nor contingent is indicated, the individual or entity will be The following individual(s) or entity(ies) shall be my primary and/or contingent beneficiary(ies). deemed to be a primary beneficiary. If more than one primary beneficiary is designated and no distribution percentages are indicated, the beneficiaries will be deemed to own equal share percentages in the Roth IRA. Multiple contingent beneficiaries with no share percentage indicated will also be deemed to share equally. If any primary or contingent beneficiary dies before I do, his or her interest and the interest of his or her heirs shall terminate completely, and the percentage share of any remaining beneficiary(ies) shall be increased on a pro rata basis. If no primary beneficiary(ies) survives me, the contingent beneficiary(ies) shall acquire the designated share of my Roth IRA. No. Beneficiary’s Name and Address Date of Birth U.S. Social Security Number (required) Is this person a U.S. Citizen? Relationship Primary or Contingent 1. Yes No Primary Contingent 2. Yes Primary No Contingent Yes Primary No Contingent Yes Primary No Contingent Yes No Primary Contingent 3. 4. 5. SPOUSAL CONSENT Share % % % % % % SIGNATURES This section should be reviewed if either the trust or the residence of the Roth IRA holder is located in a community or marital property state and the Roth IRA holder is married. Due to the important tax consequences of giving up one’s community property interest, individuals signing this section should consult with a competent tax or legal advisor. CURRENT MARITAL STATUS I Am Not Married - I understand that if I become married in the future, I must complete a new Roth IRA Designation Of Beneficiary form. I Am Married - I understand that if I choose to designate a primary beneficiary other than my spouse, my spouse must sign below. CONSENT OF SPOUSE I am the spouse of the above-named Roth IRA holder. I acknowledge that I have received a fair and reasonable disclosure of my spouse’s property and financial obligations. Due to the important tax consequences of giving up my interest in this Roth IRA, I have been advised to see a tax professional. I hereby give the Roth IRA holder any interest I have in the funds or property deposited in this Roth IRA and consent to the beneficiary designation(s) indicated above. I assume full responsibility for any adverse consequences that may result. No tax or legal advice was given to me by the Custodian. Important: Please read before signing. I understand the eligibility requirements for the type of Roth IRA deposit I am making and I state that I do qualify to make the deposit. I have received a copy of the Application, 5305-RA Plan Agreement, the Financial Disclosure and the Disclosure Statement. I understand that the terms and conditions which apply to this Roth IRA are contained in this Application and the Plan Agreement. I agree to be bound by those terms and conditions. Within seven (7) days from the date I open this Roth IRA I may revoke it without penalty by mailing or delivering a written notice to the Custodian. I assume complete responsibility for: 1. Determining that I am eligible for a Roth IRA each year I make a contribution. 2. Ensuring that all contributions I make are within the limits set forth by the tax laws. 3. The tax consequences of any contribution (including rollover contributions and conversions) and distributions. ___________________________________________ _________________ Acceptance by Scottrade, Inc. ___________________________________________ _________________ (Signature of Spouse) (Date) X ___________________________________________ _________________ (Accountholder) (Date) ___________________________________________ _________________ (Authorized Signature of Custodian) (Date) The Plan shall be deemed to have been accepted by Scottrade, Inc. upon receipt of all necessary forms, properly completed. RETURN COPY WITH “SCOTTRADE BROKERAGE ACCOUNT APPLICATION” TO SCOTTRADE, INC. Page 2 of 2 (Date) ©2009 Ascensus, Inc., Brainerd, MN