Fillable Rollover Form - Quest Ira (Page 2 of 2) in pdf

Quest IRA, Inc.

17171 Park Row, Suite 100

Houston, TX 77084

Rollover Form

P: 800.320.5950

F: 281.646.9701

Part 2. Rollover/Direct Rollover From an Employer Plan

[ ] I certify that the following statements are true and correct:

1. The undersigned certifies that my employer’s qualified plan, qualified annuity, 403(b) plan, governmental 457(b) plan, or the Federal Employees’ Thrift Savings Plan has made

or will make an Eligible Rollover Distribution which is either being paid in a Direct Rollover to the Custodian of my IRA, or paid directly to me which I am rolling over no later than

the 60th day after receiving the Eligible Rollover Distribution.

2. This Rollover/Direct Rollover is not part of a series of payments over my life expectancy or over a period of 10 years or more.

3. This Rollover/Direct Rollover does not include any required minimum distributions with respect to the employer’s plan.

4. This Rollover/Direct Rollover does not include a hardship distribution, a corrective distribution, or a deemed distribution of a default from any employer’s plan.

5. I certify that I am eligible to establish an IRA with this Rollover/Direct Rollover of an Eligible Rollover Distribution, and that I am one of the following: the plan participant, the

surviving spouse of the deceased plan participant; or the spouse or former spouse of the plan participant under a Qualified Domestic Relations Order.

6. I certify that this Rollover/Direct Rollover does not contain a distribution from a Designated Roth Contribution Account.

Part 3. Additional Information for Rollovers Beginning at Age 70 ½

I received the distribution from the other plan on __________________________. This distribution [ ] is [ ] is not an outstanding rollover as of the prior December 31st.

I certify that this rollover does not include any required minimum distribution from the distributing plan, or I certify that I have already satisfied my required minimum

distribution for the IRA being rolled over from another IRA

FOR ROTH ROLLOVERS:

PLEASE SELECT ONE OF THE FOLLOWING:

Part 1. Rollover From Another Roth IRA

[ ] I certify that the following statements are true and correct:

1. This rollover contribution is being made within 60 days after my receipt of funds from another Roth IRA in which I was either the participant or surviving spouse beneficiary. In

the case of a distribution from a Roth IRA due to a first time homebuyer which is being rolled into this Roth IRA because of a delay in the acquisition of the first time home, this

contribution is being made within 120 days after my receipt of funds from the distributing Roth IRA.

2. During the 12-month period prior to my receipt of the distribution being rolled over, I have not received a distribution from the same Roth IRA, which was subsequently rolled

over to another Roth IRA, and the distribution being rolled over has not been part of a distribution from another Roth IRA that was subsequently rolled over. (This rule does not

apply to a delay in the acquisition of a residence for a first time homebuyer.)

Part 2. Conversion From Traditional IRA to Roth IRA

[ ] I certify that the following statements are true and correct:

1. If an amount was distributed from a traditional IRA, this conversion contribution is being made within 60 days after my receipt of funds from my traditional IRA.

Part 3. Rollover From a Designated Roth Contribution Account

This is a [ ] direct rollover or a [ ] 60-day rollover from the Designated Roth Contribution Account under my employer’s §401(k) or §403(b) plan, and I certify that the following

statements are true and correct:

1. I certify that my employer’s qualified §401(k) plan or §403(b) plan has made or will make an Eligible Rollover Distribution that is either being paid in a Direct Rollover to the

Custodian of my Roth IRA, or paid directly to me that I am rolling over to my Roth IRA no later than the 60th day after receiving the Eligible Rollover Distribution.

2. This rollover/direct rollover solely represents all or a portion of my Designated Roth Contribution Account under the employer’s plan and no other account under the

employer’s plan is being rolled over to my Roth IRA.

3. This rollover/direct rollover is not part of a series of payments over my life expectancy or over a period of 10 years or more.

4. This rollover/direct rollover does not include (1) any required minimum distribution with respect to the employer’s plan; (2) any hardship distribution; (3) any corrective

distribution; or (4) any deemed distribution from an employer’s plan.

5. I certify that I am eligible to establish a Roth IRA with this rollover/direct rollover of an Eligible Rollover Distribution from a Designated Roth Contribution Account, and that I

am one of the following: the plan participant; the surviving spouse of the deceased plan participant; the spouse or former spouse of the plan participant under a Qualified

Domestic Relations Order; or a nonspouse beneficiary but only if this is a direct rollover to an Inherited Roth IRA.

Part 4. Rollover Conversion From an Employer’s Plan to Roth IRA

[ ] I certify that the following statements are true and correct:

1. This rollover conversion contribution is being made within 60 days after my receipt of funds from my employer plan or is being paid in a direct rollover.

2. I understand that the taxable portion of this rollover conversion is includible in my gross income.

3. I certify that I am eligible to make a conversion.

Part 5. Rollover Contribution of the Military Death Gratuity and SGLI Payments

[ ] I certify that the following statements are true and correct and that I am the recipient of one or both of the following eligible rollover payments:

1. This rollover contribution is being made within one year after my receipt of a military death gratuity payment and does not exceed $100,000.

2. This rollover contribution is being made within one year after my receipt of a SGLI payment and does not exceed $400,000.

E. SIGNATURE OF ACCOUNT HOLDER:

The undersigned hereby irrevocably elects, pursuant to IRS Regulation 1.402(a)(5)-1T to treat this contribution as a rollover contribution. I acknowledge that, due to the complexities

involved in the tax treatment of rollovers between Roth IRAs, conversions from traditional IRAs and employer plans, rollovers from a Designated Roth Contribution Account under an

employer’s plan and rollovers of the military death gratuity and SGLI payments, Quest IRA, Inc. has recommended that I consult with my tax advisor or the IRS before completing this

transaction to make certain that this transaction qualifies as a valid contribution and is appropriate in my individual circumstances. I understand that these transactions are reported to the

IRS and I acknowledge that I am responsible for record keeping Roth IRA contribution information as directed by the IRS. I hereby release Quest IRA, Inc. and the Custodian from any claim for

damages on account of the failure of this transaction to qualify as a valid rollover contribution or conversion.

Signature: ______________________________________________________ Date: __________________________

Print Name: _____________________________________________________

2 of 2