Legal Rollover Form

LEGAL ROLLOVER FORM

This Legal Rollover Form (the "Agreement") is made and entered into on by and between Client Name: , with primary address: (\"Transferor\"), and Receiving Institution Name: , with primary address: (\"Transferee\").

RECITALS

WHEREAS, Transferor is the beneficial owner of certain retirement or investment assets described below and desires to effect a rollover transfer of such assets to Transferee in accordance with the instructions and authorizations set forth herein; and

WHEREAS, Transferee is willing to accept such rollover transfer and to hold and administer the transferred assets subject to the terms of this Agreement and any applicable plan or custodial agreement; and

WHEREAS, the parties desire to set forth their respective authorizations, representations, transfer mechanics, and indemnities with respect to the rollover transfer.

NOW, THEREFORE

In consideration of the mutual covenants contained herein and for other good and valuable consideration, the receipt of which is hereby acknowledged, the parties agree as follows:

1. DEFINITIONS

For purposes of this Agreement, the following terms shall have the meanings ascribed below: "Assets" means the securities, cash, or other property described in Section 2; "Effective Date" means the date set forth in the opening paragraph; "Direct Rollover" means a trustee-to-trustee transfer of retirement assets without distribution to the individual; "Indirect Rollover" means a distribution to the Transferor that is subsequently redeposited to another plan or account.

2. DESCRIPTION OF ASSETS AND INSTRUCTIONS

Rollover Type (check one): Direct Rollover (trustee-to-trustee) Indirect Rollover (distribution to Transferor)

Requested Transfer Date:

3. AUTHORIZATION

Transferor hereby authorizes and directs any current custodian, plan administrator, or recordkeeper holding the Assets to transfer and deliver such Assets to Transferee in accordance with the instructions contained in this Agreement. Transferor authorizes Transferee to receive and to hold the Assets subject to its standard account agreements and any applicable plan documents.

4. REPRESENTATIONS AND WARRANTIES

Transferor represents and warrants that (a) Transferor is the lawful owner of the Assets and has full authority to direct the rollover; (b) the Assets are free of liens and encumbrances except as disclosed in writing to Transferee; and (c) if an Indirect Rollover is selected, Transferor understands any tax withholding or reporting consequences that may result and will comply with applicable timeframes for redepositing distributions.

Transferee represents that it is authorized to receive retirement or investment assets and will apply received Assets in accordance with its account agreements and applicable law.

5. TAX WITHHOLDING AND REPORTING

Each party acknowledges that tax treatment of a rollover depends on the type of transfer. Transferor shall be solely responsible for determining the tax consequences of the rollover and for any tax reporting or withholding applicable to distributions made in connection with an Indirect Rollover unless otherwise required by law. Transferee shall provide such reporting to tax authorities as required by applicable law and plan documents.

6. INDEMNIFICATION

Transferor agrees to indemnify, defend and hold harmless Transferee, its affiliates, agents and representatives from and against any claims, losses, liabilities, damages, costs and expenses (including reasonable attorneys' fees) arising out of Transferor's breach of any representation or warranty herein, any incorrect information provided by Transferor, or Transferor's failure to comply with applicable tax or plan rules.

7. CONFIDENTIALITY

The parties shall maintain confidential all nonpublic information received in connection with the rollover, except as required by law, regulation, or as necessary to effect the transfer. Disclosure to affiliates, service providers, or regulators for legitimate business purposes is permitted provided that such recipients are bound by confidentiality obligations.

8. NOTICES

All notices required or permitted under this Agreement shall be in writing and delivered to the addresses set forth below or to any other address provided in writing by a party pursuant to this section. Notices shall be deemed given when delivered personally, sent by nationally recognized overnight courier, or upon receipt if sent by certified mail.

9. AMENDMENT; WAIVER

No amendment, modification or waiver of any provision of this Agreement shall be effective unless in writing and signed by both parties. No failure or delay by either party in exercising any right shall operate as a waiver of that right.

10. GOVERNING LAW

This Agreement shall be governed by and construed in accordance with the laws of the state specified below without regard to its conflict of laws principles.

11. ENTIRE AGREEMENT; SEVERABILITY

This Agreement, together with any attachments executed contemporaneously, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior agreements and understandings. If any provision is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

12. COUNTERPARTS

This Agreement may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one and the same instrument. Signatures transmitted by electronic means shall be deemed to be original signatures for all purposes.

13. REPRESENTATIVE CONTACTS

CERTIFICATION

Transferor certifies under penalty of perjury that the information provided in this Agreement is true, complete and accurate to the best of Transferor's knowledge and that Transferor has the authority to direct the rollover. Transferor further acknowledges that any misstatement or omission may subject Transferor to liability.

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