EverSafe® Trusted Contact Authorization Form*

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EverSafe®

TRUSTED CONTACT AUTHORIZATION FORM

I [CUSTOMER NAME] designate the individual(s) listed below to be my Trusted Contact(s), and understand that in doing so I am authorizing representatives from [FINANCIAL INSTITUTION], and its affiliates, to share financial information, including non-public personal information¹ relating to my account(s), with the designated Trusted Contact(s) listed below, in the sole discretion of [FINANCIAL INSTITUTION].² This authorization applies to any current or future accounts I may maintain at [FINANCIAL INSTITUTION].

I understand that a representative from [FINANCIAL INSTITUTION], and its affiliates, may notify my designated Trusted Contact(s) to share information that includes, but is not limited to, any and/or all information related to suspected exploitation, relevant conversations related to financial information that I have previously provided to [FINANCIAL INSTITUTION], and observations and/or concerns relating to my physical and/or mental capacity if there is evidence suggesting that I am not capable of making decisions relating to my financial affairs in a manner that is consistent with my history and well-being.

I understand that financial information that may be shared by representatives from [FINANCIAL INSTITUTION], and its affiliates, with my designated Trusted Contact(s) includes, but is not limited to, any and/or all information related to my financial account(s), securities, assets, products and/or services.

I understand that my designated Trusted Contact will not have the power, pursuant to this document, to act on my behalf as an agent or to make decisions regarding my finances, unless otherwise legally authorized to do so. I acknowledge that it is suggested by [FINANCIAL INSTITUTION] that the designated Trusted Contact should not be an individual who is currently authorized to conduct business on my account(s).

I understand that representatives from [FINANCIAL INSTITUTION] may, in their discretion, communicate with my Trusted Contact(s) in order to confirm that they have been notified about the designation. Unless otherwise specified in writing, the most current designated Trusted Contact(s) will be deemed to supercede any previous such authorization. I may withdraw or change this designation at any time, as long as [FINANCIAL INSTITUTION] is notified in writing.

I acknowledge and understand that there is no requirement that [FINANCIAL INSTITUTION] notify my designated Trusted Contact(s) and that should [FINANCIAL INSTITUTION] decide to reach out to one of my Trusted Contacts, there is no obligation to reach out to all of my designated Trusted Contacts. I agree that by signing below, I and my heirs agree to indemnify and hold [FINANCIAL INSTITUTION] harmless if they act, or fail to act, based upon their discretion and best judgement.

¹“Non-public personal information” includes, but is not limited to, personally identifiable financial information provided by a customer or otherwise resulting from a transaction where a financial product or service is being provided to the customer/client. Examples include, but are not limited to, the following: account balance(s), ACH number, bank account number(s), credit card information, date of birth, location of birth, driver’s license information, income history, payment history, social security number, and tax return information.

²See FINRA Rules 2165 & 4512

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Trusted Contact(s) Trusted Contact #1 Trusted Contact #2
First Name, Last Name
Relationship to Account Holder
Address
Home Address Line 1
Home Address Line 2
Business Name
Business Address Line 1
Business Address Line 2
Email Address
Phone (Personal)
Phone (Business)


Account numbers include, but are not limited to:

    


In signing this form, I authorize [
FINANCIAL INSTITUTION] to notify and share information with my designated Trusted Contact(s) with respect to any and/or all existing and new accounts held at [FINANCIAL INSTITUTION], and its affiliates, as specified above, with the following limitations:

Specify limitations/exclusions with respect to designations/account(s) here:

 

 

 

Customer Name Customer Signature
Date  

 

Do you wish to have your designated Trusted Contact(s) receive alerts with respect to erratic activity on your account(s) and/or potential identity theft?

       Yes (email trustedcontact@eversafe.com)

       No

       Learn more (www.eversafe.com/trusted-advocates)

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*This template is for informational use and financial institutions are advised to consult their legal departments before implementation.