DIVIDEND REINVESTMENT AUTHORIZATION
PLEASE NOTE: Dividend reinvestment is available on margin eligible securities. Generally, this includes
all U.S. listed stocks, including Nasdaq issues valued at greater than or equal to $4.00 a share.
Select ONE of the following options:
Check this box to reinvest dividends on all eligible securities in your brokerage account.
• The account must contain at least one security to have the entire account coded for dividend
Complete the section below to reinvest dividends on selected securities only held in your account. Check
the delete box to discontinue dividend reinvestment.
• Mark an "X" in either the Add or Delete column.
Cusip #/ Symbol/ ADP #
CORRESPONDENT FIRM NAME
Fax this completed form to (866) 283-6097 or call (888) 859-9826.
Please type or print clearly in BLUE or BLACK ink.
Ridge Clearing &