Employee 401k Incoming Transfer Form

Employee 401k Incoming Transfer Form

Employee Information

Employee Name:

Date of Birth:   Last 4 of SSN:   Employee ID:

Position Information

Reporting Manager:   Start Date:

Receiving Plan Information (Employer Plan)

Plan Name:   Plan Sponsor:

Transferor (Current/Previous Plan or Custodian)

Transferor Plan Type: 401(k) 403(b) IRA Other

Transfer Instructions and Elections

Type of Rollover: Direct rollover (trustee-to-trustee) Indirect rollover (distribution payable to employee)

Amount to Transfer: Entire account balance Partial:

Tax Withholding and Roth Designation

Roth Conversion Election: Convert transferred after-tax or pretax amounts to Roth (if permitted) Do not convert to Roth

I understand that a direct rollover of eligible retirement plan assets to this receiving plan is generally not subject to mandatory federal tax withholding. If I elect an indirect rollover or distribution to me, applicable tax withholding rules may apply. I elect:

Default withholding as required by law for any distribution not directly rolled over Elect to have no voluntary withholding for amounts distributed to me (if permitted)

Authorization to Obtain and Transfer

By signing below I hereby authorize the current custodian/plan administrator named above to release account information and distribute funds, securities, or other plan assets as indicated in this form to the receiving plan sponsor or custodian. I authorize the receiving plan sponsor and its agents to request and obtain any records necessary to effect the transfer of assets on my behalf, including account balances, contribution histories, vested amounts, and distribution options.

I certify that I am the participant named on this form and that the information provided is complete and accurate. I acknowledge that the receiving plan's acceptance of transferred assets is subject to plan terms and that the plan administrator may require additional documentation. I understand that rollover of pre-tax amounts to a Roth account may create a taxable event and I accept responsibility for any tax consequences.

Employment History

Most Recent Employer

Dates Employed:   Reason for Leaving:

Prior Employer

Dates Employed:   Reason for Leaving:

Education

Graduation Date:

References

Reference 1

Reference 2

Reference 3

Legal Disclosures

At-Will Employment: Nothing in this form is intended to create any contractual right to employment for a definite term. Employment with the plan sponsor is at-will and may be terminated by either the employee or the employer at any time, with or without cause or notice, unless otherwise provided by a separate written agreement signed by an authorized representative.

Equal Opportunity: The plan sponsor is an equal opportunity employer. No person will be discriminated against on the basis of race, color, religion, sex, national origin, age, disability, or other protected characteristic in accordance with applicable law.

Applicant Certification & Authorizations

I certify that all information provided on this form is true, complete, and correct to the best of my knowledge. I authorize the receiving plan sponsor and its agents to effect the transfer described herein and to contact the transferor plan, custodian, or financial institution to obtain any records or documentation necessary to complete the transfer.

I authorize the plan sponsor and its designated agents to contact previous employers listed on this form for verification of employment information and to conduct background checks as permitted by applicable law. I understand that any false statement or omission of material fact may be grounds for denial of this transfer request or other corrective action.

I authorize background checks and employment verification as described above.

Additional Notes / Instructions

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