Roth Conversion/recharacterization Request Page 3
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3ROTH CONVERSION/RECHARACTERIZATION REQUEST
I. PARTICIPANT INFORMATION
NAME:
SOCIAL SECURITY NUMBER:
STATE OF RESIDENCE:
(For state tax purposes)
II. CONVERSION INSTRUCTIONS
(Move the assets as instructed below)
FROM TRADITIONAL IRA ACCOUNT NUMBER:
TO ROTH IRA ACCOUNT NUMBER:
NOTE: Converting assets from your IRA to a Roth IRA has income tax consequences. See the instructions for further details.
III. RECHARACTERIZATION INSTRUCTIONS
RECHARACTERIZE MY: J CONVERSION
J CONTRIBUTION
RECHARACTERIZE MY CONTRIBUTION:
FROM TRADITIONAL IRA ACCOUNT NUMBER:
FROM ROTH IRA ACCOUNT NUMBER:
TO ROTH IRA ACCOUNT NUMBER:
TO TRADITIONAL IRA ACCOUNT NUMBER:
DATE OF CONVERSION/CONTRIBUTION (MM/DD/YYYY): _______ /______ /_________
NET INCOME EARNED WHILE CONVERTED/CONTRIBUTED: $ _______________
IV. CONVERSION OR RECHARACTERIZATION AMOUNT
(Select one)
A. J CONVERSION:
B. J RECHARACTERIZATION:
J FULL CONVERSION — Move all cash and securities
J FULL RECHARACTERIZATION — Move all cash and securities
J PARTIAL CONVERSION*
J PARTIAL RECHARACTERIZATION*
*FOR PARTIAL CONVERSION OR RECHARACTERIZATION MOVE ONLY THOSE ASSETS LISTED BELOW:
J MOVE CASH AND/OR MONEY MARKET FUNDS IN
J MOVE THE FOLLOWING SECURITIES: (if more space is needed, attach a separate sheet.)
THE AMOUNT OF: $ ______________________
DESCRIPTION
QUANTITY
_____________________________
___________
_____________________________
___________
V. TAX WITHHOLDING ELECTION
(Please read the tax withholding instructions)
NOTE: Recharacterizations are exempt from tax withholding.
FEDERAL INCOME TAX WITHHOLDING (Select one)
STATE INCOME TAX WITHHOLDING (Rates are subject to change without notice)
If an election is not made below, 10% will be automatically withheld.
If an election is not made, we will withhold from your conversion according to your
state of residence requirement.
J DO NOT WITHHOLD FEDERAL INCOME TAX FROM THE ROTH CONVERSION AMOUNT.
J DO NOT WITHHOLD STATE INCOME TAX FROM THE ROTH CONVERSION AMOUNT.
J WITHHOLD 10% FEDERAL INCOME TAX FROM THE ROTH CONVERSION AMOUNT.
J WITHHOLD STATE INCOME TAX FROM THE ROTH CONVERSION AMOUNT ACCORDING
J WITHHOLD ___________ % FEDERAL INCOME TAX FROM THE ROTH
TO MY STATE OF RESIDENCY.
CONVERSION AMOUNT (Must be at least 10%).
J WITHHOLD $___________________ OF FEDERAL INCOME TAX FROM THE ROTH
J WITHHOLD ___________ % STATE INCOME TAX BASED ON THE ROTH CONVERSION
AMOUNT.
CONVERSION AMOUNT (Must be equal to or greater than 10%).
NOTE: State income tax withholding may be required when you elect federal
J WITHHOLD $_______________ OF STATE INCOME TAX FROM THE ROTH CONVERSION
income tax withholding.
AMOUNT.
VI. PARTICIPANT SIGNATURE
CERTIFICATION
AND
(See the attached instructions)
SIGNATURE:
DATE:
PLEASE RETURN TO:
Pershing LLC
Attention: Retirement Products Department
One Pershing Plaza
Jersey City, New Jersey 07399
ROTHC
Pershing LLC, a subsidiary of The Bank of New York Mellon Corporation
PAGE 3 0F 3
Member FINRA, NYSE, SIPC
FRM-ROTH-RECH-11-07
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