Financial Counseling Program Application Form

Select one of the plan options below

Payment Information
that I have read and accept the Disclosure Statement and Privacy Policy

By entering your e-mail address and checking the consent box, you authorize Stacey Braun to provide materials regarding Stacey Braun and its financial counseling services by e-mail.  Please note, no confidential information will be sent by e-mail.  You may withdraw consent for e-delivery or request paper copies of any documents at any time for no additional charge.

Stacey Braun Disclosure Statement and Acknowledgment:

1) Endorsement of Financial Counseling Program Service.
There is no affiliation between the NYSUT Member Benefits Corporation (“Corporation”) and Stacey Braun other than the contractual endorsement relationship referenced below. The Stacey Braun Associates, Inc. Financial Counseling Program is a NYSUT Member Benefits Corporation (Member Benefits)-endorsed program. Under an agreement with Stacey Braun, Member Benefits has an endorsement arrangement of 10% of annual participation fees received for the Full Program and 5% for the Advisor Option plus $9 per direct bill participant. All such payments to Member Benefits are used solely to defray the costs of administering its various programs and, where appropriate, to enhance them. Member Benefits acts as your advocate; please contact Member Benefits at 800-626-8101 if you experience a problem with any endorsed program.

2) Scope of Services.
While Stacey Braun’s provision of financial counseling services under the above-referenced agreement may address a wide variety of issues and topics, there may be instances where matters are beyond the scope of Stacey Braun’s area of expertise. Stacey Braun reserves the right to decline to provide advice to Participants about issues and topics outside its area of expertise. At a Participant’s request, Stacey Braun may provide recommendations to the Participant as to alternative sources of professional advice to address such issues and topics. This service may not replace the need for the Participant to utilize the services of an accountant, attorney, broker, financial planner or other professional.

3) Risk.
Participant recognizes that any financial plan or other advice provided by Stacey Braun pursuant to the above-referenced agreement with the Corporation involves Stacey Braun’s judgment and views regarding the economy and the securities markets, as well as historical trends, and like all predictions of future events or results, cannot be guaranteed as being accurate. Participant acknowledges that no party has made any guarantee, either oral or written, that the Participant’s investment objectives will be achieved. In the absence of malfeasance, negligence, or violation of applicable law, Stacey Braun will not be liable for any action performed or omitted to be performed or for any errors of judgment or mistake in preparing the financial advice or plan. Nothing in this statement shall constitute a waiver or limitation of any rights, which the Participant may have under applicable state or federal law, including without limitation, state and federal securities laws. The Participant acknowledges that advice provided is solely that of Stacey Braun and is in no way related to that of NYSUT, the NYSUT Member Benefits Trust, or the Corporation as noted in the above-referenced agreement between Stacey Braun and the Corporation. Accordingly, the Participant acknowledges that NYSUT, the NYSUT Member Benefits Trust, and the Corporation, their respective affiliates (including NYSUT Groups as defined in the above-referenced agreement), agents, trustees, directors, officers and employees, have no liability for any damages that may result from the services rendered hereunder, including reasonable attorney’s fees incurred as a result of litigation.

4) Acknowledgement.
Participant acknowledges that this Disclosure Statement and Acknowledgment has been read and accepted and that Participant has received a copy of Stacey Braun’s Privacy Policy. Upon receipt of Participant’s signed enrollment form, Stacey Braun will promptly deliver a copy of its ADV Part II to Participant.


Stacey Braun Associates, Inc.
July 2009

Stacey Braun Associates, Inc. is committed to maintaining customer confidentiality. Title V of the Gramm-Leach-Bliley Act of 1999 and the Securities and Exchange Commission's Regulations S-P (17 C.F.R. Part 248, effective 7-1-2001) require that we provide our customers with a notice explaining how we treat nonpublic personal information. We appreciate this opportunity to clarify our privacy practices for you as a result of this law.

  • Categories of Information We Collect: As part of our business, we obtain certain "nonpublic personal information" about you, which for ease of reading we will refer to as "Customer Information" in this notice. Customer Information includes, but is not limited to your name, address, telephone numbers, social security number, tax identification number (if any), financial circumstances, income and account holdings. We collect Customer Information about you from the following sources: information we receive from you included on applications or other forms; written or electronic correspondence, and telephone contacts with us; information about your transactions with us or others; and other information made available from a third party.
  • Confidentiality and Security of Customer Information: We restrict access to Customer Information to authorized individuals who need to know this information to provide services to you. We maintain physical, electronic, and procedural safeguards that comply with federal standards to protect your Customer Information.
  • Categories of Information We Disclose: We do not disclose Customer Information about you to anyone, except as permitted or required by law. We may, for example, share information with non affiliated third parties at your direction or in order to service your account or process transactions for you.
  • Former Customers: If you are no longer a customer of Stacey Braun, we will continue to treat all nonpublic personal information about you as set forth in this Notice.

We are committed to serve your interest only and consider your confidence as a crucial part of fulfilling our fiduciary duty.

You do not need to call or do anything as a result of this notice. It is meant to inform you of how we safeguard your Customer Information. You may wish to file this notice with your important papers.