Custodian Information. (required if investing through a self-directed IXX) Entity Name: Jurisdiction: Principal Address: Primary Contact: Email: Phone: Taxpayer Identification Number:
Custodian Information. If the investment in being held in a brokerage account or through a third-party custodian please enter the information below. Contact info will be used for valuation, distributions, & tax information. ADDITIONAL SUBSCRIBER INFORMATION Iroquois Valley requires information for all natural persons associated with the investment. Please complete the following information for all natural persons associated with, or benefitting from, the investment. ADDITIONAL PERSON ONE Name: Social Security Number: Address: Phone: Email: Date of Birth: Citizenship: Include as Investment Contact with access to online investor portal? o YES o NO ADDITIONAL PERSON TWO Name: Social Security Number: Address: Phone: Email: Date of Birth: Citizenship: Include as Investment Contact with access to online investor portal? o YES o NO ADDITIONAL PERSON THREE Name: Social Security Number: Address: Phone: Email: Date of Birth: Citizenship: Include as Investment Contact with access to online investor portal? o YES o NO ADDITIONAL PERSON FOUR Name: Social Security Number: Address: Phone: Email: Date of Birth: Citizenship: Include as Investment Contact with access to online investor portal? o YES o NO
Custodian Information. Healthcare Bank, 0000 00xx Xxx XX, Xxxxx, XX 00000. Healthcare Bank is a division of State Bank & Trust, a wholly owned subsidiary of State Bankshares, Inc. Designation of Representative by Accountholder The Health Savings Account (“HSA”) Accountholder named on the Healthcare Bank Custodial Agreement and Disclosure Statement (“Accountholder”) hereby appoints, designates, and authorizes HealthSCOPE Benefits ("TPA") to serve as its Designated Representative and HSA Administrator. The TPA hereby accepts the appointment by the Accountholder, subject to the terms and conditions set forth below.
Custodian Information. Upon acceptance of the Adoption Agreement, the name and address of the Plan’s Custodian will be: Fidelity Management Trust Company P.O. Box 770002 Cincinnati, OH 45277-0086
Custodian Information. If the investment in being held in a brokerage account or through a third-party custodian please enter the information below. Contact info will be used for valuation, distributions, & tax in formation. Custodian Company:_____________________________________________ Custodian Contact Person(s):______________________________________ Address:______________________________________________________ Email(s): ______________________________ Use as Contact: ❑ YES ❑ NO Phone:_________________________ Relationship to Investment:________
Custodian Information. Healthcare Bank, 0000 00xx Xxx XX, Xxxxx, XX 00000. Healthcare Bank is a division of Bell State Bank & Trust, a wholly owned subsidiary of State Bankshares, Inc.
Custodian Information. If applicable, please provide the following information:2 Custodian Name: Custodian Tax ID: Custodian’s W9 Form Please print, sign, and scan this page if applicable. See Appendix A for supplemental documents requirements by investor type. Custodian Signature / Stamp 2 This section is applicable to investors that are investing through a third-party intermediary. Fidelity Private Credit Fund | Subscription Agreement 3
Custodian Information. State Bank of Cross Plains, 0000 X. Xxxx Xxxxxx, Xxxxx Xxxxxx, XX 00000. State Bank of Cross Plains is a Wisconsin, state-chartered bank and wholly owned subsidiary of
Custodian Information. Healthcare Bank, 0000 00xx Xxx XX, Xxxxx, XX 00000. Healthcare Bank is a division of Bell State Bank & Trust, a wholly owned subsidiary of State Bankshares, Inc. Designation of Representative by Accountholder The Health Savings Account (“HSA”) Accountholder named on the Healthcare Bank Custodial Agreement and Disclosure Statement (“Accountholder”) hereby appoints, designates, and authorizes EBS-RMSCO, Inc. (“TPA”) to serve as its Designated Representative and HSA Administrator. EBS-RMSCO, Inc. xxxxxx accepts the appointment by the Accountholder, subject to the terms and conditions set forth below.
Custodian Information. Healthcare Bank, 3100 00xx Xxx XX, Xxxxx, XX 00000. Xxalthcare Bank is a division of Bell State Bank & Trust, a wholly owned subsidiary of State Bankshares, Inc.
