Employee 401K Rollover Form

EMPLOYEE 401K ROLLOVER FORM

Employee Information

Employee Name:

Phone:    Email:

Employee ID:    Date of Birth:

Position & Employment

Job Title:    Department:

Reporting Manager:    Hire Date:

Current Retirement Account to be Rolled Over

Select Account Type: 401(k) Roth 401(k) 403(b) IRA Other

Distribution Requested: Full Rollover Partial Rollover Cash Distribution

Receiving Plan / Custodian Information

Receiving Account Type:    Receiving Account Number:

Transfer Method: Trustee-to-Trustee Transfer Check Payable to Receiving Custodian (FBO Employee) Electronic Transfer (EFT)

Tax Withholding & Tax Treatment

I understand that a direct rollover to an eligible retirement plan or IRA is generally not subject to federal income tax at the time of transfer. If I elect an indirect rollover or take a cash distribution, mandatory withholding and tax consequences may apply. I elect:

Direct rollover to receiving plan (non-taxable) Indirect rollover / cash distribution (may be taxable)

Authorization, Certifications, and Acknowledgements

By signing below I certify under penalty of perjury that the information provided on this form is true and complete. I authorize the plan sponsor, plan administrator, and current custodian to release any information necessary to effect the rollover and to transfer plan assets in accordance with my instructions. I acknowledge that my election to roll over funds may be irrevocable once processed and that tax consequences may result from distributions not directly rolled over into an eligible retirement account.

I release and hold harmless the employer, plan sponsor and plan administrator from liability for processing the rollover in reliance on this form and the information provided. I authorize the plan administrator to rely on facsimile or electronic copies of this instruction and agree that such copies shall have the same force and effect as originals.

Spousal consent may be required under the terms of the current plan. If my marital status requires spousal consent, I understand that the plan will obtain a separate spousal consent form and that processing may be delayed until the consent is received.

Employment History (for verification purposes)

Title:    Dates Employed:

Title:    Dates Employed:

Education

Graduation Date:

Professional References

Phone:    Email:

Phone:    Email:

Phone:    Email:

Legal Disclosures

At-Will Employment: Submission of this form is not a contract of employment. Employment status is governed by the employer's policies and applicable law. Nothing in this form alters the at-will nature of employment unless a separate written agreement signed by authorized representatives exists.

Equal Opportunity: The employer is an equal opportunity employer. Decisions related to rollover processing are made without regard to race, color, religion, sex, national origin, disability, age, or any other protected characteristic.

Employee Certification

I certify that all information I have provided is true and complete. I authorize the release and exchange of information as necessary to execute this rollover. I accept responsibility for any tax liabilities that may arise from my election and agree to indemnify the employer and plan administrator for actions taken in good faith pursuant to this instruction.

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