Direct Conversion Request Form
Download a blank fillable Direct Conversion Request Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Direct Conversion Request Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3*SF2350*
SF2350/11-15
DIRECT CONVERSION REQUEST
The term IRA will be used below to mean Traditional IRA and SIMPLE IRA, unless otherwise specified.
IRA HOLDER’S NAME AND ADDRESS (Converting IRA)
CURRENT IRA CUSTODIAN’S NAME AND ADDRESS
IRA Account Identification
Type of IRA
Custodian’s
Social Security Number
Date of Birth
Home Phone
(Converting IRA)
(Converting IRA)
Phone Number
Traditional IRA
SIMPLE IRA
CONVERSION INSTRUCTIONS
Directly convert
all or
part of my IRA balance to my Roth IRA in the manner listed below.
Please convert $ _________________________ in cash and/or Convert Assets as listed below.
DIRECT CONVERSION REQUIREMENTS
(To be an eligible direct conversion, all questions must be answered either NO or N/A.)
1. 70
⁄
CONVERSION RESTRICTION
1
2
If you are age 70
⁄
or older in this calendar year, does the conversion contribution contain any amounts which
1
2
constitute a required minimum distribution? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
N/A
2. RECONVERSION RESTRICTION
If this is a reconversion of a prior conversion, is it within the same taxable year of the prior conversion or, if later,
within 30 days of recharacterizing the prior conversion? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
N/A
3. TWO-YEAR RESTRICTION
If this is a conversion from a SIMPLE IRA, has it been less than two years since you first participated in a SIMPLE IRA
plan sponsored by your employer? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
N/A
CAUTION: Limits apply to the number of reconversions which can be made for tax purposes.
WITHHOLDING ELECTION (Form W-4P/OMB No. 1545-0074)
See Page 2 of this form for the withholding notice information. If you are a nonresident alien, do not complete this section.
Withhold federal income tax at a rate of _____________% (not less than 10 percent) from the amount withdrawn.
Withhold additional federal income tax of _____________________ (complete only if applicable).
Effective _____________________ , I elect not to have federal income tax withheld. I understand that I am still liable for the payment of federal income
tax on the amount received. I also understand that I may be subject to federal income tax penalties under the estimated tax payment rules if my payments of
the estimated tax and withholding are insufficient.
Withhold state tax at a rate of ________% from the amount withdrawn. Indicate state of residence_____________________ (complete only if applicable).
Effective _____________________ , I elect not to have state income tax withheld.
ASSET HANDLING INSTRUCTIONS
Asset
Quantity or Amount
Quantity or Amount
Liquidate
Liquidate At
Directly
Description
In IRA
To Be Converted
Immediately
Maturity
Convert In Kind
1.
2.
3.
4.
SIGNATURE
ACCEPTING ROTH IRA CUSTODIAN
I have read and understand the conversion rules and conditions on both
The Roth IRA designated by the above-named individual is a valid Roth
pages of this form and I have met the requirements for making a Roth IRA
IRA. The undersigned hereby agrees to serve as the Custodian for the
conversion of the funds or property listed above. Due to the important tax
Roth IRA of the above-named individual and, in that capacity, agrees to
consequences of converting funds or property to a Roth IRA, I have been
accept the direct conversion of the assets listed above.
advised to see a tax professional. All information provided by me is true and
Account Number of Scottrade
®
Accepting Roth IRA ____________________
correct and may be relied on by the Custodian. I assume full responsibility for
this conversion transaction and will not hold the Custodian liable for any
_______________________________________________________
adverse consequences that may result.
_______________________________________________________
I hereby irrevocably designate this contribution of the funds and/or property
_______________________________________________________
indicated above as a conversion contribution.
_______________________________________________________
___________________________________________
_______________
___________________________________________
________________
(Roth IRA Holder)
(Date)
(Authorized Signature of New Trustee or Custodian)
(Date)
Signature Page
Signature Verification Via
Application
ID
Associate Initials
Scottrade, Inc. - Member
FINRA
and
SIPC
Page 1 of 3
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business