Internal Use Only

9017

B R O K E R A G E A C C O U N T D I S C L O S U R E

9017 v8 RF 04.17.2013 Page 1 of 2

MEMBER FINRA/SIPC

Individuals associated with M Holdings Securities, Inc. (M Securities) are required to notify M Securities in writing prior to opening an account or placing an initial order for the purchase or sale of securities with any broker/dealer, investment adviser, issuer (e.g., limited partnership or private placement), or other financial institution. Reportable accounts and securities holdings established prior to the individual’s association with M Securities must be disclosed in writing promptly upon association, and kept current thereafter. Reportable Securities: All accounts, including M Securities Pershing accounts, in which you currently hold individual securities, such as stocks or bonds, including: 1) all personal and 401(k) accounts held by you or one of your immediate family members*, and 2) all accounts in which you have a financial interest, such as accounts in which you act with discretionary authority (e.g., power or attorney, trustee). Other reportable securities held outside of brokerage accounts, such as stock certificates, must also be disclosed. * An immediate family member includes (i) spouse, (ii) life partner, (iii) children or, (iv) other relatives who live in your household or receive your material financial support. You DO NOT need to report: Accounts consisting solely of open-end mutual funds, 529 savings plans, variable life insurance policies, variable annuities, unit investment trusts (UITs), direct obligations of the U.S. Government (Treasury bills, notes and bonds, U.S. savings bonds), coins or precious metals, money market investments/funds and instruments – bankers’ acceptances, bank certificates of deposit, commercial paper, and debt instruments, including repurchase agreements. I DO NOT currently have securities accounts or holdings to report (Please sign and date below) I HAVE an account to report (Please sign and date below, and complete the remainder of the form)

By completing this disclosure form, you certify that the information provided, including reportable holdings on the attached account statements (minus account value changes due to market fluctuation) if applicable, is complete and accurate as of the date signed. This form also serves as authorization for M Securities to request and receive duplicate statements for the listed accounts. Any new securities accounts or holdings, whether held with the same financial institution or with a new financial institution, will need to be disclosed.

Printed Name of Account Owner/Trustee or Authorized Individual Social Security Number or TIN

Signature of Account Owner/Trustee or Authorized Individual Date SECTION 1 – Account Information You are required to attach the most recent account statement for each account listed. If securities are held outside of a brokerage account and statements are not available, you are required to complete Section 2.

Firm Name

Account Number. If not available, please enter TBD.

Firm Mailing Address and Phone Number

Account Registration

To disclose additional accounts, please use page 2.

B R O K E R A G E A C C O U N T D I S C L O S U R E

9017 v8 RF 04.17.2013 Page 2 of 2

MEMBER FINRA/SIPC

Firm Name

Account Number. If not available, please enter TBD.

Firm Mailing Address and Phone Number

Account Registration

Firm Name

Account Number. If not available, please enter TBD.

Firm Mailing Address and Phone Number

Account Registration

Firm Name

Account Number. If not available, please enter TBD.

Firm Mailing Address and Phone Number

Account Registration

Firm Name

Account Number. If not available, please enter TBD.

Firm Mailing Address and Phone Number

Account Registration

SECTION 2 – Securities held outside of brokerage account(s)

Security Name Custodian or

Brokerage Firm Symbol Shares/Face Units/Bonds

Current Account Balance