Financial IRA Form

FINANCIAL IRA FORM

Account Owner Information

Account Owner Name:

Account Type and Entity

Select Account Type (check one):
Traditional IRA Roth IRA SEP IRA SIMPLE IRA Inherited (Beneficiary) IRA

Contribution, Rollover, Transfer Instructions

Transaction Type (check all that apply):
New Contribution Rollover Trustee-to-Trustee Transfer Roth Conversion

Beneficiary Designation

Primary Beneficiaries — allocate 100% among primary beneficiaries. If more than three beneficiaries, attach additional page.

Investment & Account Instructions

Certifications and Acknowledgments

By signing below, I certify under penalties of law that: I am the individual identified above; all contributions are made in accordance with applicable tax law and are my funds; any rollover or transfer requested herein is authorized and I direct the releasing custodian to transfer the assets as specified; I understand that excess contributions may be subject to excise taxes and it is my responsibility to monitor contribution limits; I acknowledge that conversions from a traditional IRA to a Roth IRA may have immediate tax consequences and that I am responsible for any associated tax reporting.

I authorize the custodian to act on these instructions and to obtain and provide information to effect transfers or rollovers. I agree to indemnify and hold harmless the custodian for actions taken in good faith in reliance on this form. This form revokes prior beneficiary designations for the account unless specifically stated otherwise in writing.

I certify that the information provided is true and correct to the best of my knowledge and that I have read and understand the terms and conditions contained in this form. I understand that this form does not constitute tax advice and that I should consult a tax advisor regarding the tax consequences of contributions, rollovers, conversions, and distributions.

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