EX-22.4 6 v05163_ex22c-iv.txt Exhibit 22(c)(iv) [LOGO OF BRIDGES INVESTMENT FUND, INC.] IRA APPLICATION For Traditional, Roth, SEP, and SIMPLE IRAs
Mail to: Bridges Investment Fund, Inc. Overnight Express Mail to: Bridges Investment Fund, Inc. c/o U.S. Bancorp Fund Services, LLC c/o U.S. Bancorp Fund Services, LLC PO Box 701 615 E. Michigan St. FL 3 Milwaukee, WI 53201-0701 Milwaukee, WI 53202-5207 For additional information, please call toll-free 1-866-934-4700. ------------------------------------------------------------------------------------------------------------------------------------ In compliance with the USA PATRIOT Act, all mutual funds are required to obtain the following information for all registered owners and all authorized individuals: FULL NAME, DATE OF BIRTH, SOCIAL SECURITY NUMBER, AND PERMANENT STREET ADDRESS. This information will be used to verify your true identity. We will return your application if any of this information is missing, and we may request additional information for you for verification purposes. In the rare event that we are unable to verify your identity, the Fund reserves the right to redeem your account as an age-appropriate distribution at the current day's net asset value. ------------------------------------------------------------------------------------------------------------------------------------ 1. INVESTOR INFORMATION ___________________________ _____ _________________________________________ FIRST NAME M.I. LAST NAME __________________________________ _________________________________________ SOCIAL SECURITY NUMBER BIRTHDATE (Mo / Dy / Yr ) __________________________________ _________________________________________ DRIVER'S LICENSE OR STATE ID NUMBER STATE OF ISSUE ------------------------------------------------------------------------------------------------------------------------------------ 2. PERMANENT STREET ADDRESS Mailing Address (No foreign addresses) (Residential Address or Principal Place of Business - |_| If completed, this address will be used as the Address No PO Box addresses or foreign addresses) of Record for all statements, checks, and required mailings. _____________________________________ __________ STREET APT / SUITE ______________________________ _____ __________ ___________________________________ __________ CITY STATE ZIP CODE STREET APT / SUITE _________________________ ______________________ ____________________________ _____ __________ DAYTIME PHONE NUMBER EVENING PHONE NUMBER CITY STATE ZIP CODE ------------------------------------------------------------------------------------------------------------------------------------ 3. TYPE OF IRA CHOOSE ONE OF THE FOLLOWING ACCOUNT TYPES: If no tax year is |_| Traditional IRA Account indicated, |_| For tax year ______________ we will assume it is |_| IRA to IRA Transfer (please complete IRA Transfer Form) for the current tax |_| Rollover (shareholder had receipt of funds) year. |_| IRA Rollover Account |_| Rollover IRA to Rollover IRA Refer to disclosure |_| Direct Rollover from qualified plan - complete any additional form(s) required by statement for your Plan eligibility Administrator. Please check the type of qualified plan: requirements and |_| Corporate |_| Pension |_| PSP |_| 401(k) |_| 403(b) |_| Other ___________________ contribution limits. |_| Roth IRA Account |_| For tax year ______________ |_| Roth IRA to Roth IRA Transfer (please complete IRA Transfer Form) |_| Traditional IRA to Roth IRA - year of conversion ______ in which Traditional IRA was converted to Roth IRA |_| Rollover from Roth IRA (shareholder had receipt of funds) |_| SEP (Simplified Employee Pension Plan) -- Each employee must complete an IRA Application. |_| Contribution |_| Transfer from another SEP IRA Account |_| Rollover (shareholder had receipt of funds) |_| SIMPLE IRA (Be sure to complete Section 9)
4. INVESTMENT AMOUNT |_| By check: Make check payable to The Bridges Investment Fund, Inc. $ ________________ ($1000 Minimum) |_| By wire: Call 1-866-934-4700. Indicate amount of wire: $ ________________ ------------------------------------------------------------------------------------------------------------------------------------ 5. AUTOMATIC INVESTMENT PLAN If you choose this option, funds will be automatically transferred from your bank account monthly. Please attach a voided check to Section 7 of this application. We Your signed application are unable to debit mutual fund or pass-through ("for further credit") accounts. must be received at least 15 business days prior to PLEASE KEEP IN MIND THAT: initial transaction. o There is a $25 fee if the automatic purchase cannot be made (assessed by redeeming shares from your account). o Participation in the plan will be terminated upon redemption of all shares. Amount per Draw ($100 Minimum) AIP Start Month AIP Start Day $_______________________________ ________________________________ _________________________________ ------------------------------------------------------------------------------------------------------------------------------------ 6. VOIDED CHECK Please attach a voided check to this application if you chose the Automatic Investment Plan or the EFT option for your Systematic Withdrawal Plan. We are unable to debit or credit Your signed application mutual fund or pass-through ("for further credit") accounts. Please contact your financial must be received at least institution to determine if it participates in the Automated Clearing House system (ACH). 15 business days prior to initial transaction. Please include a voided bank check. ATTACH VOIDED CHECK HERE ------------------------------------------------------------------------------------------------------------------------------------ 7. BENEFICIARY INFORMATION (IF YOU NEED MORE SPACE, PLEASE ENCLOSE A SEPARATE SHEET OF PAPER.) PRIMARY _____________________________ ____________ __________________ ____________________ _______ _______ NAME RELATIONSHIP CITY / STATE / ZIP SOCIAL SECURITY NUMBER DOB % _____________________________ ____________ __________________ ____________________ _______ _______ NAME RELATIONSHIP CITY / STATE / ZIP SOCIAL SECURITY NUMBER DOB % _____________________________ ____________ __________________ ____________________ _______ _______ NAME RELATIONSHIP CITY / STATE / ZIP SOCIAL SECURITY NUMBER DOB % SECONDARY _____________________________ ____________ __________________ ____________________ _______ _______ NAME RELATIONSHIP CITY / STATE / ZIP SOCIAL SECURITY NUMBER DOB % _____________________________ ____________ __________________ ____________________ _______ _______ NAME RELATIONSHIP CITY / STATE / ZIP SOCIAL SECURITY NUMBER DOB % _____________________________ ____________ __________________ ____________________ _______ _______ NAME RELATIONSHIP CITY / STATE / ZIP SOCIAL SECURITY NUMBER DOB % Spousal Consent: If you name someone other than or in addition to your spouse as primary beneficiary and reside in a community or marital property state, including AZ, CA, ID, LA, NV, NM, TX, WA, and WI, your spouse must consent by signing below. X___________________________________________________ ________________________ SIGNATURE OF SPOUSE DATE ------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------ 8. SIGNATURE I have read and understand the Disclosure Statement and Custodial Account Agreement. I adopt The Bridges Investment Fund, Inc. Custodial Account Agreement, as it may be revised from time to time, and appoint the Custodian or its agent to perform those functions and appropriate administrative services specified. I have received and read the prospectus for The Bridges Investment Fund, Inc. (the "Fund"). I understand the Fund's objectives and policies and agree to be bound to the terms of the prospectus. Before I request an exchange, I will obtain the current prospectus for each Fund. I acknowledge and consent to the householding (i.e. consolidation of mailings) of documents such as prospectuses, shareholder reports, proxies, and other similar documents. I may contact the Fund to revoke my consent. I agree to notify the Fund of any errors or discrepancies within 45 days after the date of the statement confirming a transaction. The statement will be deemed to be correct, and the Fund and its transfer agent shall not be liable if I fail to notify The Bridges Investment Fund, Inc. within such time period. I certify that I am of legal age and have the legal capacity to make this purchase. If I am opening a Traditional IRA with a distribution from an employer-sponsored retirement plan, I elect to treat the distribution as a partial or total distribution and certify that the distribution qualifies as a rollover contribution. I understand that the fees relating to my account may be collected by redeeming sufficient shares. The custodian may change the fee schedule at any time. I authorize the Fund to perform a credit check in the event that one is needed to verify or establish identity. The Fund, its transfer agent, and any officers, directors, employees, or agents of these entities (collectively " Bridges Investment Fund, Inc.") will not be responsible for banking system delays beyond their control. By completing sections 5 and 6, I authorize my bank to honor all entries to my bank account initiated through U.S. Bank, NA, on behalf of the applicable Fund. Bridges Investment Fund, Inc. will not be liable for acting upon instruction believed to be genuine and in accordance with the procedures described in the prospectus or the rules of the Automated Clearing House. When AIP transactions are presented, sufficient collected funds must be in my account to pay them. I agree that my bank's treatment and rights to respect each entry shall be the same as if it were signed by me personally. I agree that if any such entries are dishonored with good or sufficient cause, my bank shall be under no liability whatsoever. I further agree that any such authorization, unless previously terminated by my bank in writing, is to remain in effect until the Fund's transfer agent receives and has had reasonable amount of time to act upon a written notice of revocation. ______________________________________________________ ________________________ DEPOSITOR / LEGALLY RESPONSIBLE INDIVIDUAL'S SIGNATURE DATE (Mo / Dy / Yr) Appointment as trustee accepted: U.S. Bank, NA /s/ [Illegible] ------------------------------------------------------------------------------------------------------------------------------------ 9. SIMPLE IRA PLANS ONLY _______________________________________________________________________________________________________ EMPLOYER (COMPANY) NAME EMPLOYER INFORMATION _______________________________________________________________________________________________________ EMPLOYER STREET ADDRESS _______________________________________________________________________________________________________ EMPLOYER CITY / STATE / ZIP CODE _______________________________________________________________________________________________________ EMPLOYER CONTACT (NAME) _______________________________________________________________________________________________________ EMPLOYER CONTACT BUSINESS PHONE NUMBER ------------------------------------------------------------------------------------------------------------------------------------ 10. DEALER INFORMATION _______________________________________________ _____________________________________________________ Please be sure to DEALER NAME REPRESENTATIVE'S LAST NAME FIRST NAME MI complete representative's DEALER HEAD OFFICE INFORMATION: REPRESENTATIVE'S BRANCH OFFICE INFORMATION: first name and middle initial. _______________________________________________ _____________________________________________________ ADDRESS ADDRESS _______________________________________________ _____________________________________________________ CITY / STATE / ZIP CITY / STATE / ZIP _______________________________________________ _____________________________________________________ TELEPHONE NUMBER TELEPHONE NUMBER ------------------------------------------------------------------------------------------------------------------------------------ BEFORE YOU MAIL, HAVE YOU: |_| Completed all USA PATRIOT Act required information? |_| Enclosed your check made payable to The Bridges - Social Security or Tax ID number in Section 1? Investment Fund, Inc.? - Birth date in Section 1? |_| Included a voided check, if applicable? - Full name in Section 1? |_| Signed your application in Section 8? - Permanent street address in Section 2?