Change of Broker/Dealer and/or Representative Authorization

Change of Broker/Dealer and/or Representative Authorization

The Change of Broker/Dealer and/or Representative Authorization is used to change the rep on an account from the current rep to a Mutual Securities Inc (MSI) rep. As it stands today, that rep is Randal Carson. 

In most cases, this form will have been provided to you as part of your transition to MSI. 

1) Indicate Change of Broker/Dealer Authorization under Request Type

2) Select whether this is for a Mutual Fund or 529, or an Insurance or Annuity Account


3) If a Mutual Fund or 529 Account, please enter the name of the Mutual Fund or 529 Company, the name of the account, the Product Name and the related account number(s) at that company. 


4) If an Insurance or Annuity Company, please enter the name of the Insurance or Annuity Company, the name of the account, the Product Name, and the related account number(s) at that company. 
      a) Ensure the MSI rep name is completed (Randal Carson)


5) Under Broker/Dealer and Agent information, fill out the Present Broker/Dealer Name, Present Rep Name, and Present Rep ID number. 
      a) The New Broker/Dealer is Mutual Securities, Inc. 
      b) The New Rep Name is Randal Carson
      c) The New Rep ID will have been provided to you ahead of your transition with us
      d) The New Branch Number is 1001
      e) The New Branch Address is 807-A Camarillo Springs Road, Camarillo, CA 93012


6) Under Signature and Dates, print the names of all account owners of the listed accounts. Ensure all account owners of the listed accounts sign and date the form. This can be done using either a physical signature or DocuSign with KBA authentication. No signature stamps are allowed. If there are more than 2 owners, please complete an additional form for the additional owners. 


7) For Internal Use Only - This is where a Home Office Principal will print their name, sign, and date the form prior to it being sent to the product company for processing. Please do not fill in this section.



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