Account Number / Rep. No.
Complete online, print & sign as appropriate.
“X” One : ACAT & Non-ACAT Processed by HQ: BTIN / Non-ACAT processed by Branch: BTNA / Piper Jaffray Clearing No.: 311
A. TYPE OF TRANSFER
“X” OneTotal Partial
Broker/Dealer Change / “X” One
Cash/Margin
Qualified / Coverdell Education Savings Account (ESA)
Direct Rollover (attach former employer’s distribution form) / IRA
Roth IRA
B. DELIVERING FIRM ACCOUNT INFORMATION
Firm Name& Address
(6 lines max.)
(Address required if
Non-ACAT) / Account Number / Clearing Number / SSN/TIN (Primary)
Account Title (from prior statement) / SSN/TIN (Secondary)
C. TRANSFER INSTRUCTIONS - (Complete ONLY part 1, 2, 3 or 4 below).
1. BROKERAGE OR TRUST COMPANY
“X” One / 1. Transfer ALL assets In-kind (Do not Liquidate) 2. Liquidate entire account and transfer. 3. Transfer only assets listed below.
Quantity / Description Of Asset (Attach additional sheet if necessary). / Action (For # 3 above only)
Liquidate / Transfer In-kind
Liquidate / Transfer In-kind
Liquidate / Transfer In-kind
2. BANK, SAVINGS & LOAN OR CREDIT UNION (See page two for delivery instructions).
Cash Options / Full Transfer (all cash in account) / Partial Transfer (must provide exact amount) Only $
CD / Annuity / Liquidate IMMEDIATELY. I am aware of and acknowledge the penalty I will incur from early withdrawal.
Options / Liquidate at MATURITY. Maturity date: / (Please submit 2-3 weeks before maturity date).
3. MUTUAL FUND COMPANY - (Use a separate form for each Mutual Fund Company)
Name of Fund / Fund Account # / # of Shares or “All” / Handling (“X” One) / Omnibus Account
(Piper Jaffray Use)
Transfer Shares In-Kind / Sell & Transfer Cash
Mutual fund dividends and capital gains will automatically reinvest. Please instruct your financial advisor if you wish to change these options.
4. INSURANCE COMPANY ANNUITY TRANSFER (For annuity transfers in-kind, please obtain the appropriate Insurance Co. form).
Reference to the Delivering Firm: If this is a retirement account, a custodial owner and custodial beneficiary change will be processed direct at the Insurance Company. If the insurance position has a systematic investment and/or withdrawal program running with the old custodian, then you will need to have these programs re-established with Piper Jaffray. / Signature Confirmation: I/we acknowledge that by signing this transfer form, I/we authorize the change of broker/dealer for any insurance assets correlating to my/our above referenced brokerage account.
Annuity Options:
Liquidate IMMEDIATELY. I am aware of and acknowledge the penalty I may incur from early termination.
Liquidate at RENEWAL. Renewal Date: / (Please submit 2-3 weeks before renewal date).
D. CLIENT AUTHORIZATION
I understand that this Authorization contains Automated Client Account Transfer (ACAT) Information on page two Section E.Client Signature (Participant Signature if Small Business Plan / Responsible Individual Signature if Coverdell ESA)
X
/ Date / Place Medallion Stamp HereClient Signature (Trustee Signature if Small Business Plan)
X
/ DateDiscrepancies of Account Name and Type (Optional)
If the account that you are transferring is in an individual's name and your Piper Jaffray account is a joint account (i.e., in more than one individual's name) then each joint account holder must sign below. We hereby authorize a transfer from the individual's account named above to the joint account at Piper Jaffray.
Joint Client Signature / Date
X
/ Print Name / Joint Client Signature / DateX
/ Print NameImportant Notice – Age 70½ restriction / To the Resigning Trustee or Custodian: Letter of Acceptance
If you are age 70½ or older in this year and are requesting a direct rollover, you must take a Required Minimum Distribution (RMD) from your Qualified Plan prior to the direct rollover occurring. Instruct your current custodian to distribute your RMD directly to you. / This is to advise you that Piper Jaffray, an IRS approved custodian, will accept the above-captioned retirement plan as successor custodian.
X
/Piper Jaffray as Custodian Authorized Signature
• Please include a copy of the most recent statement. • If this is a NON-ACAT transfer, please sign TWO originals. • Give a copy to the client.
Form E0217 (9/05)
Piper Jaffray
800 Nicollet Mall, Suite 800, J07N04
Minneapolis, MN 55402-7020 / ACCOUNT TRANSFER DEPARTMENTACAT & NON-ACAT…….612 303-6700
E. AUTOMATED CLIENT ACCOUNT TRANSFER (ACAT) INFORMATION
To Carrying Firm: If this account is a qualified retirement account, I have amended the applicable plan so it names Piper Jaffray as successor custodian. Unless otherwise indicated, please transfer all assets in my account to Piper Jaffray. I understand that to the extent any assets in my account are not readily transferable, with or without penalties, such assets may not be transferred within the time frames required by NYSE Rule 412 or similar rule of the NASD or other designated examining authority. I authorize you to liquidate any nontransferable proprietary money market fund assets that are part of my account and transfer the resulting credit balance to Piper Jaffray. I authorize you to deduct any outstanding fees due you from the credit balance in my account. If my account does not contain a credit balance, or if the credit balance in the account is insufficient to satisfy any outstanding fees due you, I authorize / you to liquidate the assets in my account to the extent necessary to satisfy that obligation. If certificates or other investments in my account are in your physical possession, I instruct you to transfer them in good deliverable form, including affixing any necessary tax waivers, to enable the successor custodian to transfer them in its name for the purpose of sale, when and as directed by me. I understand that upon receiving a copy of this transfer instruction, you will cancel all open orders for my account on your books. I affirm that I have destroyed or returned to you credit/debit cards and/or unused checks issued to me in connection with my securities account. I understand that you will contact me with respect to the disposition of any assets in my securities account that are nontransferable.F. PIPER JAFFRAY DELIVERY INSTRUCTIONS
Send Checks To: / Piper JaffrayFAO: (Client Name)
Acct. #: (Piper Jaffray Account Number)
Attn: Account Transfer, J07N04
800 Nicollet Mall, Suite 800
Minneapolis, MN 55402-7020
All Physical Equities: / Piper Jaffray
Attn: Custody & Transfer, J07N08
800 Nicollet Mall, Suite 800
Minneapolis, MN 55402-7020
(REF: Client Name & Account Number)
Federal Wire Eligible: / (Agencies; FNMA, FHLMC (CMO), FHLB, FFCB, SLMA (MTN) US Treasuries; Notes, Bonds, Strips, Bills, Fico, Refcorp Corporates; IBRD, TVA, World Bank Notes Mortgage-Backed; FNMA, FHLMC, CMO, Pool)
ABA 021000018 BK OF NYC/PIPER
GNMAs: / BKNYC/PPT/Piper
Physical Gov’t Securities: / (Commercial papers, CDs, Bank Acceptance, Physical US Treasury Coupons)
Bank of New York
Attn: Dorothy Willis
Third Floor, Window B, Dealer Clearance
1 Wall Street
New York, NY 10015
(REF: Client Name & Account Number)
Non-DTC Eligible: / Physicals
SIAC
Attn: Broker Cashiering
First Floor
55 Water Street
New York, NY 10041
A/C Piper Jaffray (#311)
(REF: Client Name & Account Number)
Money Wires: / ABA# 091000022
U.S. Bancorp Minneapolis
Minneapolis, MN
A/C of Piper Jaffray #173103114547
For Further Credit To: (Client Name & Account Number)
DTC: / Clearing #311
(REF: Client Name & Account Number)
G. TRANSFERABLE ASSETS
Assets that CAN be Transferred In Kind / Assets that CANNOT be Transferred In Kind / Assets that MAY POSSIBLY be Transferred In Kind (Call Account Transfer Department)- Corporate Securities/Stocks/Bonds
- U.S. Government Securities
- Options
- Brokered CDs
- Unit Investment Trusts
- Foreign Stocks/Bonds
- Municipal Securities
- Mutual Funds (with Broker/Dealer agreement)
- Cash
- EE Savings Bonds
- Non-brokered CDs
- Commodities
- Life Insurance
- Real Estate
- Annuities
- Limited Partnerships
- Proprietary Mutual Funds
- Precious Metals
- Worthless Securities
- No-Load Mutual Funds
Form E217 (9/05) / Since 1895. Member SIPC & NYSE.