Retirement Account Transfer/rollover Form Page 3
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4PLEASE USE BLUE OR BLACK INK
PLEASE PRINT CLEARLY IN BLOCK CAPITAL LETTERS
5 | Federal Income Tax Withholding Election (Only complete this section if you are converting an IRA at another custodian
to an Invesco Roth IRA.)
By electing to convert your Traditional, SIMPLE, SEP, or SARSEP IRA to a Roth IRA, you are making a taxable distribution,
which will be subject to federal income tax withholding at a rate of 10% unless you check the box below to elect no withholding.
If you do not check the box below, any amounts withheld may be subject to an additional 10% premature penalty tax if
you are under age 59½.
I do not want any federal income tax withheld from my Traditional, SIMPLE, SEP, or SARSEP IRA distribution.
Please consult a tax advisor to determine if you are required to make an estimated tax payment.
6 | Authorization and Signature (Please sign and date below.)
To the current trustee/custodian/employer: I have established an Individual Retirement Account with Invesco Distributors, Inc.
and have appointed Invesco Trust Company (ITC) as the custodian. Please accept this as your authorization and instruction to
liquidate and/or transfer “in kind” the assets noted above, which your company holds for me. In accordance with my custodial
agreement and/or plan document, I authorize you to deduct any outstanding fees from the account prior to the transfer.
To Invesco Investment Services, Inc. (IIS): I certify I am not rolling over any required minimum distributions (RMDs) from
the distributing retirement plan, and I understand and acknowledge that if I have started taking RMDs from the distributing
plan, I am responsible for providing IIS with any information necessary to establish a systematic distribution for RMDs, and
that if I do not provide this information, future calculations of RMD may result in underpayments, for which I may be subject
to a 50% excise tax.
Request for Taxpayer Identification Number (Substitute Form W-9)
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued
to me), and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been
notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report
all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and
3. I am a U.S. person (including a U.S. resident alien), and
4. I am exempt from FATCA reporting.
Certification Instructions: You must cross out item 2 above if you have been notified by the IRS that you are currently
subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real
estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property,
cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than
interest and dividends, you are not required to sign the Certification, but you must provide your correct TIN.
SIGNATURE PROVISIONS
I have read, understand and agree to the foregoing form. I certify that the information which I have provided is accurate,
including, but not limited to, the representations contained in the Taxpayer Identification Number section above. I certify
that this rollover is one that I am eligible to make, and I agree to indemnify and hold harmless IIS, its affiliates, each of
their respective employees, officers, trustees, or directors, and each of the Invesco Funds from and against any and all
claims, losses, liabilities, damages and expenses that may be incurred by reason of your actions taken in accordance
with the instructions set forth herein.
Signature (Required)
Title
Date (mm/dd/yyyy)
x
Note: The current trustee/custodian may require signature to be guaranteed. Call that institution for their requirements.
Each signature must be guaranteed by a bank,
Signature Guarantee:
(Please place signature guarantee stamp below.)
broker-dealer, savings and loan association, credit
union, national securities exchange or any other
“eligible guarantor institution” as defined in rules
adopted by the Securities and Exchange Commission.
Signatures may also be guaranteed with a medallion
stamp of the STAMP program or the NYSE Medallion
Signature Program, provided that the amount of
the transaction does not exceed the relevant surety
coverage of the medallion. A signature guarantee
may NOT be obtained through a notary public.
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AIM-FRM-22 02/16
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