Tue Jan 26 2021 4:26:32 pm ET

Checks/Debit Card Application

Would you like to receive checks? Yes No

Would you like to receive a free Visa® debit card? Yes No

Note: Foreign accounts are not eligible for checks or a Visa debit card, and
IRAs are not eligible for a Visa debit card. To expedite your request, please
provide a copy of your driver's license or a state ID.

Account title: MARVIN G CORTEZ

Account number: 233163385

Mailing address: 3319 W 4TH STREET

APT 104
HATTIESBURG, MS 39401
UNITED STATES

Only account owners can be issued debit cards. Select the account holders who are requesting a debit card:

Account holder one ________________________________ Account holder three ________________________________

Account holder two ________________________________ Account holder four ________________________________

Return form to:

Fax: 866-468-6268

Mail: TD Ameritrade, Inc.

PO Box 2209
Omaha, NE 68103-2209

Please note: All account owners must sign this page. Any authorized agents with full trading authority must also sign.

Signature(s) of all account owners/authorized agents:

Signature ________________________________________________

Signature ________________________________________________

Signature ________________________________________________