Rollover Certification Form For Individual Participant
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1FORM 2A 02/17
ROLLOVER CERTIFICATION FORM for Individual Participant
ABA Retirement Funds Program (“the Program”)
Customer Contact Center: 800.348.2272
P.O. Box 5142 • Boston, MA 02206-5142
Website:
Complete this form to submit rollover contributions. A separate form must be completed for each participant’s rollover. The participant
completes section 1 and signs section 3. The Authorized Plan Representative completes section 2 and mails the original, signed form
(along with a check from the rollover institution) to the address shown above. The rollover contribution will be invested according to the
investment election established by the participant for employer contributions.
Please note: Pursuant to the American Bar Association Members Retirement Plan Basic Plan Document No. 03, a rollover contribution may
only be made by an active employee. Rollover contributions are not permitted if the participant no longer works for your firm.
Checks should be made payable to ABA Retirement Funds Program.
1. ROLLOVER INFORMATION
Participant’s Name: ______________________________________________ Social Security Number: ___ ___ ___–___ ___–___ ___ ___ ___
Daytime Phone Number ( ______ ) ______ – _____________
Rollover Amount: $ ______________________________________________________________________________________________________
Post-Tax Rollover Contribution, if any:
$____________________________________________________________________________________
Roth 401(k) Rollover Contribution, if any: $ __________________________________________________________________________________
Roth 401(k) Earnings, if any: $ ____________________________________________________________________________________________
First Date Roth 401(k) Contributions were made: ____________________________________________________________________________
The assets originated from which of the following (required):
401(a) qualified plan (R)
403(b) plan (V)
Governmental 457 plan (W)
Individual Retirement Account* (9)
SIMPLE IRA
SEP or SARSEP IRA Account (9)
Note In certain instances, rollovers are considered to be “related” for purposes of top heavy testing. This generally occurs where rollover
funds derive from a retirement plan sponsored by an employer which is related to the employer sponsoring this plan.
Check here if this amount should be denoted as a related rollover on our recordkeeping system.
2. EMPLOYER INFORMATION
Program Plan Number: ___ ___ ___ ___ ___ ___ Employer Tax ID Number: ___ ___ – ___ ___ ___ ___ ___ ___ ___ IRS Plan Number: ___ ___ ___
Employer’s Name: _______________________________________________________________________________________________________
This certifies that the enclosed rollover contribution to the plan referenced above in the ABA Retirement Funds Program from the participant
named above constitutes a qualified rollover contribution. The funds were held in a conduit IRA, contributory IRA* or eligible employer plan.
* Assets held in a non-deductible or Roth IRA (“after-tax”) may not be rolled over.
3. SIGNATURES
SIGNATURE OF PARTICIPANT
DATE
PRINT PARTICIPANT NAME
AUTHORIZED PLAN REPRESENTATIVE
DATE
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