SPC Financial, Inc. 3202 Tower Oaks Boulevard, Suite

Third Party Release Form SPC Financial, Inc. 3202 Tower Oaks Boulevard, Suite 400, Rockville, MD 20852-4216 Telephone: (301) 770-6800 • Facsimile: (301) 770-9031 I, we ____________________________________________________________________________________________________________ hereby authorize SPC Financial, Inc. to release our/my financial information to: _________________________________________________________________________________________________ for purposes of __________________________________________________________________________________________________________________. Financial information can be mailed, faxed or e-mailed.

This Third Party Release Form is in effect until revoked in writing by one of the signors. Client Signature________________________________________________________

Client Signature________________________________________________________

Print Name_________________________________________________

Print Name_________________________________________________

Date_________________________________________________

Date_________________________________________________

Investment advisory services offered through SPC Financial, Inc. Neither SPC Financial, Inc. nor Sella & Martinic, LLC are registered broker/dealers and are independent of Raymond James Financial Services, Inc.

April 2017

© Copyright 2017

3202 Tower Oaks Boulevard Suite 400 Rockville, MD 20852-4216

— Securities offered through —

301-770-6800 / www.spcfinancial.com

Raymond James Financial Services, Inc. MEMBER FINRA/SIPC