Retirement Plan Transfer Form

RETIREMENT PLAN TRANSFER FORM

Personal Information

Position & Employment Details

Plan Transfer Details

I request and authorize the transfer or rollover of retirement assets as described below. I understand that I am responsible for confirming eligibility, tax consequences, and the accuracy of the account information provided.

Direct trustee-to-trustee rollover to my receiving plan
Indirect rollover (distribution to me for redeposit) — I understand mandatory withholding and tax reporting may apply
Partial transfer (specify amount below)
Full balance transfer

Current / Originating Plan Information

Receiving Plan Information

Amount and Allocation

Total balance reported or estimated with originating plan: $ . Amount to be transferred: $ .

Tax Withholding & Tax Treatment

I understand that direct trustee-to-trustee rollovers are generally not taxable events. If an indirect rollover is selected, federal tax withholding and tax reporting rules may apply. I understand that I am responsible for confirming the tax treatment of this transfer and for timely redeposit if an indirect rollover is used.

Withhold default federal tax percentage from distribution
Do not withhold (I accept responsibility for tax reporting)
Withhold specific amount: $

Employment History (Required)

Please list your two most recent employers, including the employer associated with the originating retirement plan if different.

Education

References (Professional)

Provide three professional references who can verify employment, responsibilities and character.

Legal Disclosures & Statements

At-Will Employment: Nothing in this form alters the at-will nature of employment with the employer or the terms of existing employment agreements. Equal Opportunity: The employer is an equal opportunity employer; submission of this form will not be used to unlawfully discriminate.

Representations: I represent that I am the rightful owner or beneficiary of the originating account and that the funds requested for transfer are eligible under applicable plan terms and law for rollover or transfer. I will indemnify and hold harmless the receiving plan and plan administrator for losses resulting from incorrect or incomplete information I provide.

Authorization to Obtain Records: I authorize the plan administrator, custodian, or their agents to obtain and review records necessary to effect this transfer, including prior employer plan records, account statements, and identity verification records.

Applicant Certification & Authorization

I certify that all information provided on this form is true, complete, and accurate to the best of my knowledge. I authorize the plan administrator and receiving custodian to act on this transfer request and to accept and apply funds to the receiving account. I understand that processing may require contact with prior employers or custodians and I authorize such contacts.

I acknowledge that tax consequences may result from this transfer depending on the method chosen. I accept responsibility for complying with applicable tax requirements and will consult my tax advisor if I have questions.

Background & Employment Verification Authorization: I authorize the employer or its agent to verify any employment history information provided on this form and to perform any background checks related to employment verification that are permitted by law.

Consent to Electronic Signature: By signing below I consent to the use of electronic signatures and acknowledge that an electronic signature has the same force and effect as a handwritten signature for purposes of this form.

I certify that the information on this form is true and that I authorize the transfer described herein.

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