To print a blank form, check here: Clear

Letter of Authorization (LOA)

Sub Firm # BR Code Client Authentication
SSN/TIN (last 4 digits) Phone #
FA Code Account Number
Acct. Info.
(Office Use Only) Authenticated by QS Approval (if required)

Section 1 Tell Us About Your Brokerage Account

Account Name(s) (e.g., John Doe, John and Mary Doe, the Doe Family Trust, etc.)
Please complete
all fields in this
Account Type (e.g., Individual, Joint, Trust, etc.)
section.

Section 2 Tell Us About Your Transfer Request

One-Time Disbursement (Any future requests will require a new form)

Purpose for Transfer – required for UTMA/UGMA ____________________________________________________

Standing Instruction (Periodic transfers at the client's discretion with the amount not to exceed a specific threshold.)
If no selection is
made, one-time
Recurring* (only available for cash)
disbursement is *Automated transfer of a specific dollar amount or type
the default.
AND/OR Type(s)
Amount $: __________________________ (dividends, interest, etc.): _________________________________________________________

Start Date: __________________________ Frequency (monthly, quarterly, etc.): _______________________________________________

Expiration Date or transfers will continue until you revoke:

Section 3 Tell Us What You Want To Transfer
You may elect All Cash and Securities - does not include residuals
to distribute
cash only, All Cash and Securities - including 90 day cash residual transfer
securities only,
or both cash Cash $: or write in ALL
and securities.
Standing Instruction*
Cash Not to Exceed Dollar Value $ _________________________ * List securities below if applicable

All Securities

Only the securities listed below

Need more space? Attach separate pages including Tax Lot Selections if applicable; any attachments must also be signed.
Number of For standing instructions,
Shares/Contracts (or for provide maximum market value
Security Description Symbol or CUSIP
standing instructions, list based on prior business day's
not to exceed quantity) closing value

Investment and Insurance Products:

Not Insured by FDIC or any Federal Government Agency May Lose Value Not a Deposit of or Guaranteed by a Bank or any Bank Affiliate
Wells Fargo Advisors is a trade name used by Wells Fargo Clearing Services, LLC and Wells Fargo Advisors Financial Network, LLC, separate registered
broker-dealers and non-bank affiliates of Wells Fargo & Company.
SR #

592296 (Rev 06 - 04/18) Page 1 of 2

 Section 4 Tell Us How You Want To Move Assets
Move via Journal to another Wells Fargo Advisors Account
Time of
completion 8-Digit Account Number Account Title
varies based on
account activity
and method of Send shares to another Financial Firm
distribution. Receiving Account Number Receiving Account Name

Receiving Firm Name Delivery Instructions Firm or DTC Number

Check
Checks cannot
be mailed Payee Information – Make Check Payable To:
directly to the
IRS or other Payee Name: _______________________________________________________________________________
taxing
authorities. Delivery Instructions - Mail to Address:

Street Address City

Check cannot
be overnighted State Zip Code Country (if outside of US)
to a P.O. Box.

Optional Memo Note: __________________________________________________________________________________

Section 5 Provide Signature(s) and Date

The undersigned acknowledges that I/We have read this form in its entirety and understand and agree to be bound by this Letter of Authorization and the Terms and Conditions
located on page 2.
Account Owner/Trustee Signature Print Name Date

X
Account Owner/Trustee Signature Print Name Date

X
Physically
Confirmed by two pieces of identification
Office Use Only recognized
(e.g., SSN, account information)
Authorized Account Holder the client
Verbal
Instructions
(Contingency
Only)

Terms and Conditions

WELLS FARGO CLEARING SERVICES, LLC, ("WFA"), and Wells Fargo Bank, N.A., are separate affiliates of Wells Fargo & Company. As separate legal entities, none are
responsible for the obligations of the others. Stocks, bonds, mutual funds, and other securities bought and sold through WFA are not bank deposits of any bank and are not
insured or otherwise protected by the Federal Deposit Insurance Corporation or any other government agency; are not an obligation of any bank or any affiliate of WFA; are not
endorsed or guaranteed by Wells Fargo & Company, WFA, or any bank or any affiliate of WFA; and involve investment risk including possible loss of principal. Accounts are
carried by Wells Fargo Clearing Services, LLC, member NYSE/SIPC.
In consideration of WFA accepting the instructions on this document, I release and discharge WFA and its affiliates from any liability or claims in connection with these instructions
and agree to indemnify and hold WFA harmless against any losses from any action, claim, or demand of any person based upon WFA acting under these instructions.
For transfers to third party accounts in which you have no ownership interest, you agree that by signing this document that you are irrevocably relinquishing all rights, title, and
interest to the asset(s) listed on this document. It is your responsibility to verify the accuracy and the legitimacy of the source of instructions provided by third parties, such as title
companies, attorneys, accountants, and business associates, for transfers from your account.
I acknowledge that I have read and understand the terms of this request to transfer assets and further acknowledge that the terms of this request are binding regardless of any
other agreement(s) between me and the recipient(s) of these assets.

OFFICE USE ONLY: Associate and Supervisory Signatures

The undersigned certifies that the account holder(s) authorized the terms of the transfer of funds and/or securities as described in this form.
Associate’s Signature Associate’s Name Date
X
Qualified Supervisor's Signature Qualified Supervisor's Name Date
X

Investment and Insurance Products:

Not Insured by FDIC or any Federal Government Agency May Lose Value Not a Deposit of or Guaranteed by a Bank or any Bank Affiliate
Wells Fargo Advisors is a trade name used by Wells Fargo Clearing Services, LLC and Wells Fargo Advisors Financial Network, LLC, separate registered
broker-dealers and non-bank affiliates of Wells Fargo & Company.

592296 (Rev 06 - 04/18) Page 2 of 2