IRA Conversion Form

IRA Conversion Form

Account Owner Information

Source Account to be Converted

I hereby request conversion of assets from my existing IRA account into a Roth IRA maintained with the Custodian specified below.

Conversion Instructions

Conversion requested (select one):

Receiving Roth Account Information

Tax Withholding Election and Reporting

I acknowledge that a conversion from a pre-tax IRA to a Roth IRA is a taxable distribution for federal income tax purposes in the year converted unless other tax law provides otherwise. The Custodian will report distributions to the Internal Revenue Service and the account owner on the appropriate tax forms.

Acknowledgements and Representations

By signing below, I certify and represent all of the following under penalty of perjury:

1. I am the beneficial owner of the source account and have authority to direct distribution or transfer of the assets identified above. I authorize the Custodian to effect the conversion as instructed.

2. I understand that the amount converted is includible in gross income for federal income tax purposes unless otherwise excluded by law. I accept responsibility for any federal, state, or local taxes, penalties, and interest resulting from the conversion and will consult my tax advisor if I have questions.

3. I understand that if I am under age 59½, certain distributions and reconversions may be subject to early distribution penalties under tax law; I assume responsibility for any penalties.

4. I agree to indemnify and hold the Custodian, its agents and successors harmless from any liability, claims, losses, or expenses (including reasonable attorneys’ fees) arising from reliance on my representations, instructions, or failure to provide complete or accurate information.

5. I acknowledge that the Custodian does not provide tax or legal advice and that I have had the opportunity to consult with my own professional advisors regarding the tax consequences of this conversion.

Authorization and Certification

I hereby authorize the Custodian to effect the conversion of the assets as indicated above. I certify that the information provided on this form is true, correct, and complete to the best of my knowledge. I understand that this authorization will remain in effect until the requested conversion has been completed or until I provide written notice to the Custodian revoking this instruction, subject to any processing already in progress.

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