Ameriprise Financial Planning Service Cancellation and Refund

Ameriprise Financial Services, Inc. 70100 Ameriprise Financial Center Minneapolis, MN 55474
Ameriprise® Financial Planning Service
Cancellation and Refund Request
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Complete this form to cancel an Ameriprise Financial Planning Service
("AFPS") or ("Service") relationship and/ or request a full or partial refund
toward a financial planning engagement.
This form can also be used to cancel the Service relationship and request a
full or partial refund toward an AFPS engagement that is part of a
consolidated advisory fee relationship.
See Form 402004-inst for instructions.
Canceling an unfunded agreement may also be requested via telephone by
contacting Service Delivery.
When requesting to fully cancel the Service, scheduled arrangements such as
Systematic Payments (SPOs) and bank authorizations will also be
discontinued once this paperwork is processed. If you wish to cancel a
recurring credit card payment, you must indicate that here.
Part 1
Client ID
001
Client Information
Financial Plan Account Number
0191
Account Holder, Executor, Principal or Trustee Name
Phone Number
Business, Estate or Trust Name
Co-Account Holder, Executor, Principal or Trustee Name
Who is making this Request? (Select One)
Client (Signature required in Part 6)
CSU or Field Registered Principal (Signature required in Part 8 if mailed or faxed)
Advisor (Signature required in Part 7 if mailed or faxed)
Corporate Office (Complete Part 9)
Part 2
Request Type (Select One)
Request Type (Select One)
Cancellation Request Only
Cancellation with Refund Request (Complete Part 3)
Refund Request Only (Complete Part 4)
Is there a recurring Credit Card charge associated with this financial planning service that needs to be canceled?
Yes
No
© 2009-2013 Ameriprise Financial, Inc.
All rights reserved.
Text
402004
Advisor/CSU or Field RP signature required if mailed or faxed.
Sign on page 3
Fax # 612.547.1863
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Part 3
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Cancellation with Refund Request
Complete this part to cancel the Service and request a full or partial refund.
You may request and receive a refund of the entire fee paid during an engagement period at any time up to 30 days after the end of the
engagement period, provided that you have not received written recommendations under this Agreement. If you request a refund after you
receive written recommendations, your refund may be limited. Advisors, including terminated and/or former advisors who are part of the
Agreement, are not eligible for any refunds of Service fees.
If no Reason for Fee Refund Request is selected, the refund request will not be processed.
When requesting to fully cancel the Service, scheduled arrangements such as Systematic Payments (SPOs) and bank authorizations will
also be discontinued once this paperwork is processed. If you wish to cancel a recurring credit card payment, you must indicate that here.
Please complete Part 5 for the method of refund. If no method of refund is selected, a refund check will be mailed to the client's address of
record unless the Service fee was paid by a credit card in which case fees will be refunded to the credit card used.
Fee Refund Amount Requested
$
Reason for Fee Refund Request(must choose one; see definitions below)
Plan Year (YYYY)
Advisor Cannot Fulfill
Client Changed Mind
Client Dissatisfied with Advisor
Incorrect Payment
Client Dissatisfied with Advice/AFPS
Additional explanation for reason selected above.
Part 4
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Refund Request Only
Complete this part when continuing with the Service relationship but requesting a full or partial refund due to overpayment.
If no Reason for Fee Refund Request is selected, the refund request will not be processed.
Please complete Part 5 for the method of refund. If no method of refund is selected, a refund check will be mailed to the client's address of
record unless the Service fee was paid by a credit card in which case fees will be refunded to the credit card used.
Fee Refund Amount Requested
$
Reason for Fee Refund Request (must choose one; see definitions below)
Plan Year (YYYY)
Advisor Cannot Fulfill
Client Changed Mind
Client Dissatisfied with Advisor
Incorrect Payment
Client Dissatisfied with Advice/AFPS
Additional explanation for reason selected above.
Definition of Fee Refund Request Categories:
1. Advisor Cannot Fulfill: Advisor is unable to fulfill the terms of the service agreement. Examples: Advisor cannot reach client; advisor will
be unable to provide advice by delivery date; client deceased.
2. Client Changed Mind: Any reason unrelated to the client’s experience with AFPS or the advisor. Examples: Client experienced job loss or
death in the family, client has abandoned financial planning as an objective, advisor with whom client wanted
to engage in financial planning has left the firm.
3. Client Dissatisfied with Advice/AFPS: Any expression of client dissatisfaction with AFPS or the written financial advice promised as part of
the service. Examples: Client didn’t receive written financial planning advice, advice did not meet expectations.
4. Client Dissatisfied with Advisor: Any expression of client dissatisfaction with the advisor servicing AFPS.
5. Incorrect Payment: Refund of excess funds directed to engagement. Example: Client submits payment for engagement that is already
fully paid, resulting in need to refund fee.
Part 5
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Method of Refund (Select One)
If no method of refund is selected, a refund check will be mailed to the client's address of record unless the Service fee was paid by a
credit card in which case fees will be refunded to the credit card used.
If the Service is part of a consolidated advisory fee relationship, the refund will be applied to the account that paid the fee.
Bank authorization payments cannot be refunded back to the client's external bank account.
Credit Card (if plan was paid by credit card it will be automatically refunded to the card used)
Credit Card Number
Expiration Date (MMYY)
Send refund check to Client address on record
Send refund check to Client new address
(advisor or client must call 1.800.862.7919 Option 5, Option 6 to update new address or submit Form 518 for address changes)
Apply refund to Non-Qualified Account at Ameriprise Financial: Account Number
402004
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Part 6
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Client Signature Information
Required only if form is completed by the Client.
By submitting this form, I agree to the terms and conditions outlined and I represent the validity regarding the information provided as well
as any instructions requested.
Account Holder, Executor, Principal or Trustee Name
Date (MMDDYYYY)
Account Holder, Executor, Principal or Trustee Signature
X
Co-Account Holder, Executor, Principal or Trustee Name
Date (MMDDYYYY)
Co-Account Holder, Executor, Principal or Trustee Signature
X
Part 7
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Advisor Information and Signature (Signature required if mailed or faxed)
Required only if form is completed by the Advisor.
By submitting this form, I agree to the terms and conditions outlined and I represent the validity regarding the information provided as well
as any instructions requested.
Are you the compensated advisor for the Ameriprise Financial Planning Service plan sold to the client?
Advisor Name
Part 8
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Yes
No
Advisor Number
CSU or Field Registered Principal Information and Signature (Signature required if mailed or faxed)
Required only if form is completed by the CSU or Field Registered Principal.
By submitting this form, I agree to the terms and conditions outlined and I represent the validity regarding the information provided as well
as any instructions requested.
CSU or Field Registered Principal Name
Registered Principal Number
CSU or Field Registered Principal Signature
Date (MMDDYYYY)
X
Part 9
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Corporate Office Information
Required only if form is completed by the Corporate Office.
Corporate Office Department Name
Corporate Office Employee Name
402004
Phone Number
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