Account Holder Name Change Request
J.P. Morgan Securities LLC
Member FINRA and SIPC
You can submit this form Use this form to
and any attachments by:
• Request a change in the name on your brokerage account.
Secure Message What you need to know
Visit www.chase.com/ • This request cannot be used to change the ownership for your account.
brokerageforms for
instructions on how to • Legal documentation must be from a U.S. government source.
submit this request by
secure message. • We cannot process a name change with only a copy of your Social Security card.
Fax • The name on the Name Change Request form must match the name on all provided supporting
(800) 805-3909 documents.
Mail • For your protection, a representative may call you to confirm this transaction before it is processed.
J.P. Morgan Securities LLC • For best results, complete this form using Adobe Reader. You will need to print a copy for your signature.
Attn: Acct. Maintenance
Mail Code: IL1-0291 • Keep a copy of this request for your records.
10 S. Dearborn St.
Chicago, IL 60603-5506
If you need help, contact
our Client Service Center 1. Tell Us About Your Account
at (800) 392-5749 or
submit a secure message
through chase.com.
According to the IRS Account Holder Former Name Account Number
Form W-9 instructions, if
you are only submitting
this form for an account
you hold in the United Exemption from FACTA Reporting Code (if any) Social Security or Tax ID Number (required)
States, you may leave the
Exemption from FACTA
Reporting code field blank.
This form can't be used 2. Tell Us the Reason for Your Name Change
on checking, savings or
credit card accounts. Marriage (Please attach a copy of your marriage certificate or valid government–issued ID and Social Security
card.)
If divorce decree does
not state that the name is Divorce (Please attach a copy of your divorce decree or valid government–issued ID and Social Security card.)
being restored, please Legal Name Change (Please attach a copy of your Court Order or valid government–issued ID and Social Security
provide a copy of current
driver's license. card.)
First B-Notice (Please attach supporting legal documents or valid government–issued ID and a copy of your Social
Security card.)
Second B-Notice (Please attach supporting legal documents or valid government–issued ID and a copy of your
Social Security card.)
First or Middle Name Correction (Please attach a copy of your passport or birth certificate or valid government–
issued ID and Social Security card.)
Naturalization (Please attach a copy of your Certificate of Naturalization and Immigration Petition for Name
Change or valid government–issued ID and Social Security card.)
3. Tell Us About Your Requested Name Change
First Name
Middle Name
Last Name Suffix
INVESTMENT AND INSURANCE PRODUCTS:
• NOT A DEPOSIT • NOT FDIC INSURED • NOT INSURED BY ANY FEDERAL GOVERNMENT AGENCY
• NO BANK GUARANTEE • MAY LOSE VALUE
33652_CYI v7.0.3 Page 1 of 2
Account Holder Name Change Request
J.P. Morgan Securities LLC
Member FINRA and SIPC
4. Signature
Certification: Under penalties of perjury, the Primary Account Holder, Entity or the Minor/Protected Person
named above certifies that:
1. My correct taxpayer identification number is shown on this form.
2. I am not subject to backup withholding because (a) I am exempt from backup withholding, or (b) I have not
been notified by the IRS that I am subject to backup withholding as a result of a failure to report all interest
and dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding.
3. I am a U.S. citizen or other U.S. person (as defined in the Form W-9 instructions).
4. The Foreign Account Tax Compliance Act (FATCA) code(s) entered on this form (if any) indicating that I am
exempt from FATCA reporting is correct.
(Note: If you have been notified by the IRS that you are currently subject to backup withholding for failure to
report all interest and dividends on your tax return, you must cross out item 2 above). The IRS does not require
your consent to any provisions of this document other than the certifications required to avoid backup
withholding.
X
Account Holder Signature Date (month/day/year)
INVESTMENT AND INSURANCE PRODUCTS:
• NOT A DEPOSIT • NOT FDIC INSURED • NOT INSURED BY ANY FEDERAL GOVERNMENT AGENCY
• NO BANK GUARANTEE • MAY LOSE VALUE
33652_CYI v7.0.3 Page 2 of 2
