Transfer Request Form - Retirement Plans Division
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1
2C
F
S
USTODIAL
EE
CHEDULE
COMMUNITY
T
R
F
RANSFER
EQUEST
ORM
NATIONAL
Effective 1/2014
BANK
225 Main Street ● PO Box 225 ● Seneca KS 66538
Phone: (800)680-0340 ● Fax (785)336-6880
R
P
D
ETIREMENT
LANS
IVISION
Account Being Transferred To CNB:
Community National Bank Account Information:
(One Account Per Form)
Name of Current Custodian/Trustee
Account Owner’s Name
Physical Address Line 1
CNB Account #
New (To Be Established)
Physical Address Line 2
Account Owner’s Phone Number
City
ST
Zip
Account Owner’s Social Security Number
Date of Birth
Phone Number of Current Custodian/Trustee
For Office Use Only
Account Number at Current Custodian/Trustee
Send Transfer Request Form to Current Custodian by:
CNB will submit this transfer request form to the current custodian by USPS Priority Mail. If you prefer an expedited
service, please indicate the selected service and provide the requested information. (If a billing number is not provided,
we will send by priority mail or other method of our choice.)
Please send the transfer request form by the following Overnight Carrier:
Federal Express Billing #_________________________
UPS
Billing # ________________________
Billing Zip Code _________________
Select one:
Standard Overnight
Early Morning Delivery
Second Day Delivery
My current custodian will process a fax of this request.
(Please verify fax acceptance with current custodian.)
Fax Number: ________________________________________
Attn:_____________________________________
Return Funds to Community National Bank by:
P lease send check s by regular m ail unless a box is m ark ed below
.
Please overnight funds to CNB by Overnight Carrier
Federal Express Billing #_________________________
UPS
Billing # ________________________
Billing Zip Code _________________
Please wire funds to CNB. I understand that fees will be charged for this wire and will be deducted from the amount
received. Please refer to the CNB Fee Schedule for wire fee.
For delivery of cash or investments please see the attached CNB Delivery Instructions.
1. Transaction Type
This transaction should be reported as a:
Transfer
Direct Rollover
Please contact your employer for specific forms required to complete this transaction.
Conversion
Please check with current custodian to see if they will process from this request and if they require you to attach a W-4P.
From
To
*
Traditional IRA
Traditional IRA
Profit Sharing Plan
**
SEP IRA
SEP IRA
SIMPLE IRA
Roth IRA
Inherited Traditional IRA
Roth IRA
*
Inherited Roth IRA
Inherited Traditional IRA
401k
*
Other _____________________
Inherited Roth IRA
403b
*
Please contact your employer for specific forms required to process this request.
**
Current Custodian/Trustee is responsible for determining 2-year eligibility for transfer
from a SIMPLE IRA to a Traditional IRA.
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