Account # ______________
Branch # ________
IC# ______
LETTER OF AUTHORIZATION TO TRANSFER
FUNDS OR SECURITIES BETWEEN ACCOUNTS
Date:
__________________
I.
I herby authorize the transfer of funds and/or securities
From
Account number: ________________________________
Account name:
To
________________________________
Account number: ________________________________
Account name:
________________________________
Bank Routing Information, if applicable
II.
Bank name:
________________________________
Bank address:
________________________________
Routing number:
________________________________
Amount of funds to be transferred: ________________________________
OR
Quantity and Description of Securities to be Transferred:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
III.
Reason for the above Transfer / Special Instructions:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Signed:
______________________
Signed:
______________________
Print Name:
______________________
Print Name:
______________________
Title:
______________________
Title:
______________________
Medallion Guarantee Stamp (Optional):
Medallion Guarantee Stamp (Optional):
If more than two signatures are required, please complete additional forms as necessary.
This LOA must be received by FSI’s Margin Department no later than 2:30pm to be processed the same day.
Date Requested:
Approved By:
Rep#:
Branch#:
Principal of the firm