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Transfer on Death (TOD) Application and Agreement Sub Firm: 211 Account #: 1 Account Holder Information

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Transfer on Death (TOD) Application and Agreement Sub Firm: 211 Account #: 1 Account Holder Information Transfer on Death (TOD) Application and Agreement Sub Firm: 211 Account #: 1 Account Holder Information Account Holder(s) Name Social Security Number(s) Account Holder(s) Address City, State Zip You are applying for registration of your account in If you are married and live in a community property jurisdiction, beneficiary form thereby assigning ownership of the account you understand that if you designate a beneficiary who is not on your death to your beneficiary(ies) named within. You direct your spouse, your spouse must approve your designation of your broker and First Clearing* to transfer all TOD-eligible beneficiary by signing this form. Community property assets in this account in accordance with this application and jurisdictions are as follows: Alaska, Arizona, California, Idaho, the TOD agreement included with this application. Louisiana, Nevada, New Mexico, Texas, Washington, Wisconsin, and Puerto Rico. Note that in Alaska, community property rules You release your Broker, First Clearing, and their agents and may be adopted by agreement signed by the married couple. representatives from all claims, demands, suits, actions, liabilities and responsibilities whatsoever and agree to IF YOU ARE MARRIED AND LIVE IN A COMMUNITY PROPERTY indemnify them from any and all liabilities, cost or expense JURISDICTION, YOU UNDERSTAND THAT A SUBSEQUENT whatsoever including attorney’s fees, for acting in good faith MARRIAGE PRIOR TO YOUR DEATH MAKES THIS DESIGNATED in accordance with the instructions and the privileges selected BENEFICIARY INEFFECTIVE AND YOU UNDERSTAND THAT ANY herein. You further certify that you received and read the TOD SPOUSE TO WHOM YOU ARE MARRIED AFTER YOU MAKE agreement included with and made a part of this application. THIS DESIGNATION MUST CONSENT TO YOUR DESIGNATION. All terms of this application and agreement shall be binding Also see page four. upon your heirs, representatives and assigns. IF YOU ARE MARRIED AT THE TIME OF YOUR DEATH, AND LIVE IN A COMMUNITY PROPERTY JURISDICTION, AND IF YOUR BROKER HAS NOT ACCEPTED AN APPLICATION THAT INCLUDES THE APPROPRIATE SPOUSAL CONSENT, YOU UNDERSTAND THAT THIS BENEFICIARY DESIGNATION IS INEFFECTIVE AND THAT ALL TOD-ELIGIBLE ASSETS WILL BE DISTRIBUTED TO YOUR ESTATE. 2 Primary Beneficiary(ies) Designation At the death of the last surviving account owner and upon receipt of all required documents, your Broker will transfer all TOD-eligible assets in the account to the following primary beneficiaries who survive the last surviving account owner. Unless different percentages are indicated below, the TOD-eligible assets in the account shall be divided equally among the primary beneficiaries. The percentages designated below must add up to 100%. Note: If you designate any beneficiaries that are minors, you MUST designate a Custodian under the Uniform Transfers to Minors Act (UTMA.) (For example, list the custodian's name and indicate “as custodian for” and then list the minor's name.) You must check ONE below: If any primary beneficiary is not alive when the last surviving account owner dies or if that beneficiary disclaims his/her interest, that beneficiary’s share shall be distributed as follows: ☐ To the remaining primary beneficiary(ies) on a pro rata basis (proportionate to the designated percentages). ☐ To the applicable contingent beneficiary(ies) designated in the Contingent Beneficiary Designation section on pages 2 and 3. ☐ To the last surviving account owner’s estate. ☐ To the heirs of the pre-deceased / disclaimed primary beneficiary(ies) per stirpes. If you check this box, you must also complete the Per Stirpes Designation section on page 3. *Account(s) carried by First Clearing. First Clearing is a trade name used by Wells Fargo Clearing Services, LLC, a registered broker-dealer and non-bank affiliate of Wells Fargo & Company. Securely email, fax or mail completed form to: Page 1 of 6 TODF.2016.11.12.05 [email protected] | 352-224-1341 | PO Box 358230, Gainesville, FL 32635 Sub Firm: 211 Account #: Primary Beneficiary(ies) Designation (CONTINUED) (Please use a separate sheet if additional beneficiaries are desired. The sheet must be signed by all account owners.) Relationship to Client Beneficiary Name Social Security or Tax ID # Beneficiary Phone # 1 Designated Percentage Beneficiary Address City, State, Zip Birthday or Trust Date % Relationship to Client Beneficiary Name Social Security or Tax ID # Beneficiary Phone # 2 Designated Percentage Beneficiary Address City, State, Zip Birthday or Trust Date % Relationship to Client Beneficiary Name Social Security or Tax ID # Beneficiary Phone # 3 Designated Percentage Beneficiary Address City, State, Zip Birthday or Trust Date % Relationship to Client Beneficiary Name Social Security or Tax ID # Beneficiary Phone # 4 Designated Percentage Beneficiary Address City, State, Zip Birthday or Trust Date % Relationship to Client Beneficiary Name Social Security or Tax ID # Beneficiary Phone # 5 Designated Percentage Beneficiary Address City, State, Zip Birthday or Trust Date % Relationship to Client Beneficiary Name Social Security or Tax ID # Beneficiary Phone # 6 Designated Percentage Beneficiary Address City, State, Zip Birthday or Trust Date % 3 Contingent Beneficiary(ies) Designation (Please use a separate sheet if additional beneficiaries are desired. The sheet must be signed by all account owners.) Contingent to Primary Percentage of Primary Beneficiary Name Social Security or Tax ID # Beneficiary Number(s): Beneficiary’s Share 1 % Beneficiary Phone # Beneficiary Address City, State, Zip Birthday or Trust Date Contingent to Primary Percentage of Primary Beneficiary Name Social Security or Tax ID # Beneficiary Number(s): Beneficiary’s Share 2 % Beneficiary Phone # Beneficiary Address City, State, Zip Birthday or Trust Date Contingent to Primary Percentage of Primary Beneficiary Name Social Security or Tax ID # Beneficiary Number(s): Beneficiary’s Share 3 % Beneficiary Phone # Beneficiary Address City, State, Zip Birthday or Trust Date Securely email, fax or mail completed form to: Page 2 of 6 TODF.2016.11.12.05 [email protected] | 352-224-1341 | PO Box 358230, Gainesville, FL 32635 Sub Firm: 211 Account #: Contingent Beneficiary(ies) Designation (CONTINUED) Contingent to Primary Percentage of Primary Beneficiary Name Social Security or Tax ID # Beneficiary Number(s): Beneficiary’s Share 4 % Beneficiary Phone # Beneficiary Address City, State, Zip Birthday or Trust Date Contingent to Primary Percentage of Primary Beneficiary Name Social Security or Tax ID # Beneficiary Number(s): Beneficiary’s Share 5 % Beneficiary Phone # Beneficiary Address City, State, Zip Birthday or Trust Date Contingent to Primary Percentage of Primary Beneficiary Name Social Security or Tax ID # Beneficiary Number(s): Beneficiary’s Share 6 % Beneficiary Phone # Beneficiary Address City, State, Zip Birthday or Trust Date Optional Designation ☐ Check this box only if you would like to designate the contingent beneficiary(ies) named in this section to share in the account per stirpes. This will entitle the share of the pre-deceased / disclaimed contingent beneficiary(ies) to pass to his/her descendants. If you check this box, you must also complete the per stirpes designation section at the bottom of this page. 4 Per Stirpes Designation - OPTIONAL PER STIRPES DESIGNATION Complete this section only if you have designated primary or contingent beneficiaries to share in the account per stirpes. Per Stirpes is a method of distributing the assets should a beneficiary predecease the account holder. This designation is optional. A per stirpes designation means that if a beneficiary dies before you, upon your death, the predeceased beneficiary's share will pass to his or her descendants. For example, suppose you have named 2 primary beneficiaries, Beneficiary A and Beneficiary B. They are to share equally the assets of the account. Both Beneficiaries have 2 children. If you make a per stirpes designation and both beneficiaries survive you, 50 % will be paid to Beneficiary A and 50% will be paid to Beneficiary B. If Beneficiary A survives you but Beneficiary B predeceases you, upon your death 50% is paid to Beneficiary A, and the other 50% that would normally be paid to Beneficiary B will be divided equally and paid to the two children of Beneficiary B. If you elect to make this designation, you must designate a Personal Representative or a "role". A role is described as an executor or trustee. Upon your death, your Broker will rely on the instructions provided by this individual for proper distribution instructions. This is a simplified example of per stirpes. Before making this designation, you should obtain a complete explanation from your legal advisor. It is important that you have a full understanding prior to designating a per stirpes beneficiary. In order to make a per stirpes designation, you must have designated either the primary beneficiaries named in the Primary Beneficiary Designation section, or the contingent beneficiaries named in the Contingent Beneficiary Designation section to share in the account per stirpes. Completion of one of the following choices is also required: ☐ I designate a personal representative to provide my Broker with the proper identity of any unnamed beneficiaries and the extent of their interest in the account identified above. My personal representative will be ☐ I designate an individual serving in a specific capacity or role to provide my Broker with the proper identity of any unnamed
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