2. Primary Account Holder

Personal Information

If account is a Tenants in Common, indicate this holder’s share:

Percentage

Provide personal information on the primary individual associated with this account.

First Name

M.I.

Last Name

Date of Birth

Daytime Phone

Evening Phone

Check all that apply and provide information.

Marital Status

Single/Divorced/Widowed

Married

# of Dependents

Country of Citizenship

Country of Tax Residency

SSN

TIN

Social Security #

Taxpayer ID #

Type of Government-Issued Id

ID Number

State/Country of Id Issuance

ID Issuance Date

ID ExpirationDate

Legal Address

Cannot be a P.O. Box or Mail Drop.

Address Line 1

Address Line 2

City

State/Province

Zip/Postal

Country

Mailing Address

Same as Legal Address

Complete only if different from Legal Address above.

Address Line 1

Address Line 2

City

State/Province

Zip/Postal

Country

Employer Information and Affiliations

Provide Income Source if retired or not employed.

Check One

Employed

Retired

Non Employed

Occupation

Income Source

Employer Name

Address Line 1

Address Line 2

City

State/Province

Zip/Postal

Country

Check all that apply and provide information.

You are, or an immediate family/household member is, a senior foreign political figure.

You are, or an immediate family/household member is, a control person or affiliate of a publicly traded company under SEC Rule 144. This would include, but is not limited to, a director, 10% shareholder, policy-making officer, and members of the board of directors.

Company Name

CUSIP or Symbol

You are affiliated with, or employed by, a stock exchange, or a member firm of an exchange or Financial Industry Regulatory Authority (FINRA), or a municipal securities dealer.

Same as employer above. If different, provide the information below.

Company Name

Address Line 1

Address Line 2

City

State/Province

Zip/Postal

Country