Contribution Authorization Form

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CONTRIBUTION AUTHORIZATION
I. PARTICIPANT INFORMATION
NAME:
ACCOUNT NUMBER:
SOCIAL SECURITY NUMBER:
II. RETIREMENT PLAN TYPE
(Select one)
J TRADITIONAL IRA
J ROTH IRA
J SEP IRA
J SIMPLE IRA
J EDUCATION SAVINGS ACCOUNT
J
Special needs apply
III. CONTRIBUTION TYPE
In keeping with Internal Revenue Service (IRS) tax reporting requirements, employer contributions (including employee salary
deferrals) must be processed and reported in the year they actually occur, regardless of the year of designation. Obtain and refer to the
instructions on filing IRS Form 5498.
CURRENT YEAR
PRIOR YEAR
TOTAL DEPOSIT
IRA CONTRIBUTION
$_________________________
$_________________________
$_________________________
EDUCATION SAVINGS ACCOUNT
$_________________________
$_________________________
$_________________________
EMPLOYER OR COMPANY CONTRIBUTION
$_________________________
$_________________________
$_________________________
EMPLOYER MATCHING CONTRIBUTION
$_________________________
$_________________________
$_________________________
EMPLOYER NONELECTIVE CONTRIBUTION (SIMPLE IRA)
$_________________________
$_________________________
$_________________________
EMPLOYEE SALARY DEFERRAL CONTRIBUTION (SIMPLE IRA, SARSEP)
$_________________________
$_________________________
$_________________________
ROTH CONVERSION—CASH
$_________________________
$_________________________
ROLLOVER CASH (See certification section below)
$_________________________
$_________________________
TOTAL (The amount of your check should equal this amount)
$_________________________
$_________________________
$_________________________
CONVERSION/ROLLOVER SECURITIES (Select one and list the securities below)
J SECURITIES CONVERSION TO ROTH IRA
J ROLLOVER SECURITIES (See rollover certification section below)
DESCRIPTION
DESCRIPTION
QUANTITY
QUANTITY
NOTE: Use the Roth Conversion/Recharacterization Request for direct trustee to trustee or internal Roth conversions.
CONVERSION OR ROLLOVER CERTIFICATION
If I elect to make a conversion or rollover contribution to the retirement account indicated above, I hereby certify that I understand
the conversion or rollover rules and conditions as they pertain to this retirement account, and I have met the requirements for making
such a transaction. Due to the important tax consequences of converting or rolling over funds or property, I have been advised to
consult with a tax professional. All information provided by me is true and correct and may be relied upon by the custodian. I assume
full responsibility for these transactions and will not hold the custodian liable for any adverse consequences that may result. I hereby
irrevocably designate the conversion or rollover of funds or other property as rollover contributions.
AGE 70
1 /
CONVERSION/ROLLOVER/TRANSFER RESTRICTION
2
If you are over the age of 70
this year, you may not convert, rollover, or transfer required minimum distribution amounts. If necessary,
1 /
2
instruct your present custodian to either: 1) pay your required minimum distribution to you now; or 2) retain that amount for
distribution to you later. For Roth conversions, you must take your required minimum distribution amount before you convert your assets
to a Roth IRA.
IV. PARTICIPANT OR GUARDIAN SIGNATURE
SIGNATURE:
DATE:
Make checks payable to: Pershing LLC FBO
, and write your
account number on the check.
(Participant Name)
PLEASE RETURN TO:
Pershing LLC
Attention: Retirement Products Department
One Pershing Plaza
IRA102CTRB
Jersey City, New Jersey 07399
Pershing LLC, a subsidiary of The Bank of New York Mellon Corporation
Member FINRA, NYSE, SIPC
FRM-IRA-CA-11-07

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