PFS INVESTMENTS, INC

REQUEST FOR CHANGE OF REGISTERED REPRESENTATIVE

(This page retained by the client)

Instructions:
1.
2.
3.

Complete the Form

Sign the Form
Mail or fax (see fax service) the Form to:
Primerica Shareholder Services
PO Box 9662
Providence, RI 02940

Fax Service You may fax this request to 508-599-7734 for processing.

You may use this form to change the Primerica Financial Services Registered Representative on
a Primerica Shareholder Services account, to another Primerica Financial Services Registered
Representative.

Section 1 Representative Information:

This section must be completed when requesting a change of representative on an existing
Primerica Shareholder Service's account. Please indicate which representative this change will
apply, either primary or secondary. If you know the representatives name and solution/agent
number, for which the From and To change will apply, please list in the space provided.
Section 2 - Client Information:
If you are requesting a representative change on multiple accounts, you must use a separate
form for each account. Please provide the following client information related to their current fund
account, fund name, account number, owners name on account, last four digits of social security
number, date of birth, joint owners name, joint owners social security number, address, city,
state, zip and telephone number.
This Section Must Be Completed:
The account owner and the primary registered representative must sign the form.

PFS INVESTMENTS, INC

REQUEST FOR CHANGE OF REGISTERED REPRESENTATIVE
Mail completed form to: Primerica Shareholder Services, PO Box 9662, Providence, RI 02940, or you may fax this
request to 508-599-7734 for processing.

1.

2.

Change the Registered Representative on the below referenced account.

Primary Registered
Representative

Secondary Registered
Representative

Secondary Registered
Representative

Change From:
(If Known)

Change From:
(If Known)

Add:

Registered
Rep's Name: __________________

Registered
Registered
Rep's Name: ___________________ Rep's Name: ____________

Solution Number: ______________

Solution Number: _______________ Solution Number: ________

Change To:

Change To:

Registered
Rep's Name: __________________

Registered
Rep's Name: ___________________

Solution Number: ______________

Solution Number: _______________

Client Information: Note: One form per account

Fund Name: _____________________________________________________________________________
Account Number: ________________________________________________________________________
Owner's Name (please print): ______________________________________________________________
Owner's Social Security Number: _________________________Date of Birth:_______________________
(Last 4 Digits Only)
Joint Owners Name: _____________________________________________________________________

Joint Owners Social Security Number: ______________________________________________________

(Last 4 Digits Only)
Owner's Address: ________________________________________________________________________
City, State, Zip: __________________________________________________________________________
Owner's Telephone Number: _______________________________________________________________
3.

This section must be completed

Date:

__________________

Owner's Signature:

_____________________________________________________________

Joint Owners Signature:

________________________________________________________

Primary Registered Representative's Signature:

BD-9
2.12

_____________________________________