Roth Conversion/recharacterization Request (Page 2 of 3) in pdf

ROTH CONVERSION/RECHARACTERIZATION REQUEST INSTRUCTIONS

I. PARTICIPANT INFORMATION

Please print your name (first, middle initial, last) and fill in the boxes for Social Security Number and state of residence.

Provide a two-letter state abbreviation for state of residence.

II. CONVERSION INSTRUCTIONS

To convert your Traditional IRA to your Roth IRA, please provide the account numbers for the Traditional IRA (delivering account) and

the Roth IRA (receiving account).

Tax Consequences of a Roth Conversion: Converting assets from your Traditional IRA to a Roth IRA has income tax

consequences, including potential tax penalties that you should carefully consider. As IRA custodian, we are required by law to

report to the Internal Revenue Service (IRS) the Roth conversion from your Traditional IRA to your Roth IRA. Consult with a tax

professional to determine if you are eligible for a Roth conversion and your personal income tax liability that may result from this

transaction.

III. RECHARACTERIZATION INSTRUCTIONS

There are two types of recharacterizations. The first is the recharacterization of a contribution from one type of IRA to another;

and the other is the recharacterization of a Roth conversion back to a Traditional IRA. A taxpayer converting a Traditional IRA to

a Roth IRA and subsequently recharacterizing that conversion may not reconvert that amount until the year following the

conversion or 30 days after the recharacterization, whichever is later. Requests to reconvert the same assets immediately after

they are recharacterized cannot be accepted.

To recharacterize your Traditional IRA participant contribution to your Roth IRA, please provide the account numbers for the

Traditional IRA (delivering account) and the Roth IRA (receiving account).

To recharacterize your Roth IRA participant contribution or Roth IRA conversion to your Traditional IRA, please provide the

account numbers for the Roth IRA (delivering account) and the Traditional IRA (receiving account).

Provide the date on which the conversion or contribution was made.

State the earnings on the conversion or contribution while it was being held in the delivering account.

IV. CONVERSION OR RECHARACTERIZATION AMOUNT

A. CONVERSION

For partial conversions, indicate the dollar amount, description, and quantity of securities that you wish to convert to your Roth

IRA in the space provided. Please use the security descriptions as they appear on your brokerage account statement. If more space is

needed, attach a separate sheet. An Election of Full Conversion will close your Traditional IRA.

NOTE: Conversions may include residual income attributable to these assets paid subsequent to the conversion upon notification

from your financial organization.

B. RECHARACTERIZATION

For partial recharacterizations, indicate the dollar amount, description, and quantity of securities that you wish to recharacterize to

your Roth or Traditional IRA. Please use the security descriptions as they appear on your brokerage account statement. If more

space is needed, attach a separate sheet. An Election of Full Recharacterization will close the delivering account.

V. TAX WITHHOLDING ELECTION (

Rates are subject to change without notice)

Unless instructed otherwise, we are required to withhold federal income tax (and state income tax, depending on your residency)

from Roth conversions. You may elect not to have federal income tax withheld by completing this section. In some cases, you may

elect not to have state income tax withheld. If no election is made, 10% federal income tax and applicable state income tax will be

withheld unless you indicate otherwise. For requests to have federal income tax withholding in a dollar amount, ensure that the

amount is equal to or greater than 10% of the gross conversion amount. Penalties may be incurred under the estimated tax rules if

your withholding and/or tax payments are not sufficient for the tax year. You may revoke your election at any time before your Roth

conversion is processed. Your election remains effective until revoked. Taxes withheld from your conversion in accordance with your

instructions will not be reversed. For additional information regarding federal and state tax withholding, contact your tax

professional.

VI. PARTICIPANT SIGNATURE AND CERTIFICATION

This form cannot be processed without your signature. In the case of a minor, we must receive a guardian’s signature.

By signing this form, I certify that the information provided by me is correct and may be relied upon by the trustee or custodian.

I understand that I am responsible for determining my eligibility to convert my Traditional IRA to a Roth IRA or recharacterize within

the limits set forth by tax laws, related regulations, and plan agreements. I have been advised to see a tax professional regarding this

transaction. I assume full responsibility for this transaction and will not hold the trustee or custodian liable for any adverse tax

consequences or penalties that may result. I understand that the beneficiary information for the account receiving the assets will be in

effect as designated in writing by me. If I elect to change beneficiaries, I will submit a change of beneficiary notification acceptable

to the custodian.

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FRM-ROTH-RECH-11-07

Roth Conversion/recharacterization Request Page 2

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