Account Modification Form - TD Ameritrade

1 Page 1 of 11 TDA 189 F 03/211 Return Options:Electronically via Message Center: Log in and go to Client Services > Message Center to attach the fileRegular Mail: PO Box 2760, Omaha, NE 68103-2760 Overnight Mail: 200 South 108th Avenue Omaha, NE 68154-2631 Fax: 866-468-6268 Individual Retirement Accounts (IRAs) are not eligible to add a Co-Owner. Nonresident Alien Account Owners are only eligible for Joint Tenants with Rights of Survivorship (JTWROS) accounts. If you have additional questions, please visit our website at or call us at : If adding Account owner(s), the new owner(s) agree to be bound by any agreements, privileges, and/or features already established on the Account modifications indicated on this form will be applied to all of the above-listed accounts.

2 If you do not intend for a Modification to be made to all of the accounts listed above, you must submit a separate form for each accounts using the TD Ameritrade Investment Management, LLC advisory service: The privileges in the margin, options, and check writing sections are not applicable to TD Ameritrade Investing Accounts using the advisory service of TD Ameritrade Investment Management, LLC and any responses in these sections will not be applied to your Account . In addition to this form, you must also fill out the Personal and Financial Information Form to update your Account with any changes in your financial situation or investment Modification FormAccount # Account # Account #*TDA189* Account ModificationCC Add a Co-Owner.

3 (Please choose a joint Account type. If you are establishing a joint Account and do not check a box, the Account will be registered as Joint Tenants with Rights of Survivorship. If the Account owners do not qualify for the joint Account type selected, then the joint Account type will default to Joint Tenants with Rights of Survivorship.)State laws vary. You should consult with a tax or legal advisor to determine if the Account ownership you wish to select is available in your residents of Louisiana, if married the Account type will default to Community Property, if not married Account type will default to Tenants in Joint Tenants with Rights of Survivorship (JTWROS).

4 If a Joint owner dies, his/her interest passes to the other Account Owner. (not available to residents of Louisiana)CC Community Property. AZ, CA, ID, LA, NM, NV, PR, TX, WA, WI residents only (spouses only).CC Tenants in Common % Owner % Co-Owner (50/50, unless otherwise noted). If a Joint owner dies, his/her interest passes to his/her Remove Co-Owner. Please complete Section 2. Do not sign in Section 11, and please only sign in Section 12. If the Account has margin and/or options privileges, please complete Sections 6, and 7.

5 This form must be Notarized or have a TD Ameritrade Branch Stamp. We can accept mailed or faxed copies. Note: The primary Account Owner cannot be removed from the 2 of 11 TDA 189 F 03/21 Account Owner/Current Account InformationEmployer Name (If Self-Employed, provide the name of your business):Please choose from the list provided on page 11 the occupation code and industry of occupation code that most accurately describes your Code:Industry of Occupation Code:Employer Address:City:State:Zip Code:Country:2 First Name:Middle Name:Last Name:Name Prefix (optional): CC Mr.

6 CC Mrs. CC Ms. CC Dr. CC Status: CC Single CC Married CC Divorced C C WidowedPlease specify if you are:CC EmployedCC UnemployedCC RetiredCC HomemakerCC StudentCC Self-EmployedAnnual Income:CC $0-$24,999CC $25,000-$49,999CC $50,000-$99,999CC $100,000-$249,999CC $250,000+Approximate Net Worth: (not including primary residence)CC $0-$14,999CC $15,000-$49,999C C $50,000-$99,999CC $100,000-$249,999CC $250,000-$499,999CC $500,000-$999,999CC $1,000,000-$1,999,999CC $2,000,000+Approximate Liquid Net Worth: (cash, stocks, etc.)CC $0-$14,999CC $15,000-$49,999C C $50,000-$99,999CC $100,000-$249,999CC $250,000-$499,999CC $500,000-$999,999CC $1,000,000-$1,999,999CC $2,000,000+What best describes the ongoing source of funds for this Account ?

7 CC Employment/WagesCC Retirement FundsCC GiftCC SavingsCC Inheritance/TrustCC InvestmentsCC Unemployment/DisabilityCC Legal SettlementCC Lottery/GamingCC Spousal/Parental SupportCC Other (describe source of funds):Number of Dependents:Email (required for electronic delivery of your Account statement and trade confirmations):Page 3 of 11 TDA 189 F 03/213 Account Co-Owner InformationHome Address: (no PO box or mail drop)Mailing Address: (if different from above)City:City:State:State:Zip Code:Zip Code:Country:Country:Primary Phone number:C C Check here if this is not a phone numberFax number:Secondary Phone number:C C Check here if this is not a phone numberEmail (required for electronic delivery of your Account statement and trade confirmations):Employer Name (If Self-Employed, provide the name of your business):Please choose from the list provided on page 11 the occupation code and industry of occupation code that most accurately describes your Code:Industry of Occupation Code:Employer Address:City:State:Zip Code: Social Security Number:Date of Birth:Number of Dependents:First Name.

8 Middle Name:Last Name:Are you the Account Owner s spouse? CC Yes CC NoName Prefix (optional): CC Mr. CC Mrs. CC Ms. CC Dr. CC specify if you are:CC EmployedCC UnemployedCC RetiredCC HomemakerCC StudentCC Self-EmployedMarital Status: CC Single CC Married CC Divorced C C WidowedPage 4 of 11 TDA 189 F 03/21 Section 3, Account Co-Owner Information continued4 Affiliations Check here if the C C Account Owner or C C Co-Owner, their spouse, any member of their immediate families living in the same household, including parents, in-laws, siblings, and dependents is a member of the board of directors, 10% shareholder, or policy-making officer of a publicly traded company.

9 Specify the company name, ticker symbol, address, city, and state:Check here if the C C Account Owner or C C Co-Owner, their spouse, any member of their immediate families living in the same household, including parents, in-laws, siblings, and dependents is licensed, employed by, or associated with, a broker-dealer firm, a financial services regulator, securities exchange, or member of a securities exchange. If checked, please specify entity below. If this entity requires its approval for you to open this Account , please provide a copy of the required authorization letter (with this application):Country of Citizenship:Country of Birth:CC Check here if you are NOT a of Dual/Secondary Citizenship (if applicable) citizens*: Do you hold a current immigration visa?

10 CC Yes CC NoSpecify visa type:Visa Number:Expiration:* Nonresident aliens must submit a W-8 BEN form, a copy of a current passport, and a copy of a bank or brokerage statement. If a address is listed, then attach a Letter of Explanation for Mailing Address/Phone Number for Form W-8. This form can be found on the TD Ameritrade Forms Library: Income:CC $0-$24,999CC $25,000-$49,999CC $50,000-$99,999CC $100,000-$249,999CC $250,000+Approximate Net Worth: (not including primary residence)CC $0-$14,999CC $15,000-$49,999C C $50,000-$99,999CC $100,000-$249,999CC $250,000-$499,999CC $500,000-$999,999CC $1,000,000-$1,999,999CC $2,000,000+Approximate Liquid Net Worth: (cash, stocks, etc.)