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IRA Conversion Request Form

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IRA Conversion Request Form

Use this form to request the conversion of assets from an existing Individual Retirement Account (IRA) to a Roth IRA held at this custodian. Complete all applicable sections, sign and date the certification. Incomplete or illegible requests may delay processing.

Account Holder Information

Current Account Information (From)

Account Number:

Account Type (select one):

Conversion Destination (To)

Convert to:

Conversion Amount and Method

Conversion Instruction (select one):

Investment Handling upon Conversion (select one):

Tax Withholding Election

I understand that amounts converted from a pre-tax IRA to a Roth IRA may be taxable. Withholding is generally voluntary for conversions. Make your election below:

percent of the taxable amount

State tax withholding (if applicable): percent

Authorization and Certification

By signing below I direct the custodian to effect the conversion described above. I certify that I am the owner or authorized signatory of the account(s) referenced and have full authority to request this conversion. I understand that converted amounts may be subject to federal and state income taxes in the year of conversion and may affect my tax liability. I agree to accept responsibility for any tax or penalties arising from this conversion.

I authorize the custodian to liquidate, transfer or distribute assets as necessary to complete the conversion. To the fullest extent permitted by law, I agree to indemnify and hold the custodian harmless from any loss, liability or expense that may arise out of the custodian's good faith reliance on these instructions.

Under penalties of perjury I certify that the taxpayer identification number provided on file is correct, that I am a U.S. person (including U.S. resident alien), and that I have the authority to make this election. I have read and understand the terms of this conversion request.

Custodian Use Only

Processing action:

Account Holder Name:

Signature:

Date:

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What the IRA Conversion Request Form Does

An IRA Conversion Request Form is the written instruction an account owner submits to a custodian or trustee to convert funds from one type of individual retirement account to another (commonly Traditional or SEP to a Roth IRA). The form documents the account, conversion amount or percentage, tax-withholding election (if any), and authorization to transfer or reclassify assets. Custodians use the completed form to generate distribution reporting (Form 1099-R) and to update account status; accuracy is important for tax reporting and to avoid processing delays.

Why the Form Matters for Account Owners and Custodians

A clear, signed conversion request creates a formal record authorizing tax-reportable movement of assets, reduces processing errors, and provides an auditable trail for IRS reporting and future account administration.

Why the Form Matters for Account Owners and Custodians

Who Completes or Receives the IRA Conversion Request Form

Typical participants who prepare, submit, or receive an IRA Conversion Request Form.

  • Individual account holders — Complete personal information, choose conversion options, and sign to authorize the custodian.
  • Financial advisors / tax preparers — Prepare the form, confirm tax elections, and provide client guidance.
  • Custodians / broker-dealers — Accept the request, execute the conversion, and issue IRS reporting (1099-R).

Each role has different responsibilities for accuracy, authorization, and record retention.

Stepwise Checklist to Complete and Submit the Form

Follow these core steps in order to prepare an accurate request and minimize follow-up.

  • 01
    Gather Documents: Recent account statement and ID
  • 02
    Choose Conversion: Select full or partial conversion
  • 03
    Check Tax Election: Decide on withholding or no withholding
  • 04
    Submit to Custodian: Deliver signed form per custodian instructions

Where to Send a Completed IRA Conversion Request Form

Delivery method depends on the custodian's accepted channels and whether you use electronic or paper submission.

  • Custodian Upload: Secure portal upload to custodian
  • Email to Operations: Encrypted email per custodian policy
  • Postal Mail: Physical mailing to custodian operations
  • In-Branch Submission: Deliver signed copy to local branch

Digital Submission and eSignature Requirements

Use a secure eSignature workflow and approved file formats (PDF or DOCX) when submitting electronically to a custodian.

  • File Formats: PDF, DOCX, or scanned PDF
  • Authentication: Email link, SMS code, or KBA
  • Integrations: Salesforce, NetSuite, Google Workspace

Recommended Online Workflow Settings for eSubmission

Configure a digital workflow that enforces required fields, signer authentication, and a retained audit trail.

Field Configuration
Signature Field Required; date auto-fill enabled
Authentication Email + SMS code recommended
Conditional Fields Show withholding options when applicable
Audit Trail Retain full event log

Essential Sections to Include on a Professional Form

A complete form collects identification, specific conversion instructions, tax elections, custodian routing, and clear authorization language to satisfy operational and regulatory needs.

Account Identification

Full account registration details, including account number, account type, and current custodian name to ensure precisely targeted processing and avoid misapplied conversions.

Conversion Instruction

Clear selection of conversion type (partial, dollar amount, percentage, or full balance) with precise numeric fields to prevent ambiguity during execution.

Tax Withholding Election

Explicit checkbox and percentage or dollar fields for federal withholding elections; capturing this choice affects gross-to-net transfer amounts and tax reporting.

Beneficiary/Secondary Info

Optional but recommended beneficiary confirmation to keep account records current and avoid future probate complications or correction requests.

Custodian Processing Instructions

Routing details for cash transfers or in-kind asset reclassification, including ticker symbols or mutual fund details when applicable for accurate transfer.

Authorization Language

Signature block with printed name, date, taxpayer identification, and explicit authorization statement that the custodian can act on the request.

Required Data Elements at a Glance

Taxpayer ID: SSN or ITIN
Account Number: Custodian account number
Conversion Type: Traditional to Roth
Amount: Dollar amount or full
Withholding: Yes/No and percent
Signature: Signed and dated

Common Preparation Errors to Avoid

  • Entering an incorrect account number or custodian name that causes misapplied funds and requires manual reconciliation and correction.
  • Failing to specify withholding election or entering ambiguous withholding percentages, which results in unexpected tax liabilities for the account owner.
  • Using a name variant or missing suffixes on the signature line that fails identity verification and delays acceptance by the custodian.
  • Submitting unsigned or partially completed forms where required fields are blank, causing custodial rejection and restarting of processing timelines.

Key Risks and Consequences of Incorrect Requests

Income Tax Liability: Converted amount taxable
Early Withdrawal Penalty: Possible 10% on distributions
Reporting Errors: 1099-R mismatches
Processing Delays: Late processing risks
IRS Penalties: Accuracy-related penalties
Custodial Fees: Possible processing charges

Key Dates and Filing Deadlines to Track

Track reporting and tax deadlines so conversions are reflected in the correct tax year and supporting forms are received in time for filing.

Effective Date:

Use conversion date MM/DD/YYYY for tax year

1099-R Issuance:

Custodian issues 1099-R by Jan 31

Form 5498 Reporting:

Custodian files 5498 by May 31

Tax Return Deadline:

Include conversion on Form 1040 by Apr 15

Extension Deadline:

October 15 with timely extension

Supporting Documents Commonly Submitted with a Conversion Request

Include supporting documentation to verify identity, account authority, and the assets to be converted.

Copy of ID

Government-issued photo ID to verify the signer, often required for custodial KYC processes and identity-proofing.

Recent Account Statement

A statement showing current holdings and account number helps custodians confirm available balances and process in-kind instructions.

Beneficiary Form

Updated beneficiary designation if the conversion affects account titling or long-term estate planning considerations.

Previous Tax Documents

Prior-year Form 1099-R or account statements to assist with tax calculations and establish basis when needed.

Frequently Asked Questions About the IRA Conversion Request Form

Answers to common questions address tax treatment, eSignature acceptance, reporting, and how to correct errors on a submitted request.


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