In-Plan Roth Conversion Form - Oregon Savings Growth Plan Page 3
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4In-Plan Roth Conversion
1. plan infoRmation
Plan Name Oregon Savings Growth Plan
2. account holdeR infoRmation
Account Holder Name
Street Address/PO Box
City
State
ZIP
Primary Phone
3. amount Requested
You must be actively employed in order to convert an amount from funds not otherwise eligible for distribution.
Please select one or both of the following options:
Convert pre-tax amount of money previously contributed to the OSGP account.
A. Dollar Amount of contributions not otherwise eligible for distribution $ ____________________________
OR
B. Percent of Amount Available from contributions not otherwise eligible for distribution ________________%
Convert pre-tax amount of money previously rolled into the OSGP account from a 403(b), 401(k), 401(a) or eligible IRA account.
A. Dollar Amount of rollover money $ ____________________________
OR
B. Percent of Amount Available from rollover money ________________%
Note: If the amount available for conversion is less than the dollar amount you are requesting, the transaction will be processed for
the maximum amount available.
Please give careful consideration to your decision to convert funds from your account. Once the conversion to Roth has
been made, it is irrevocable.
4. taxes
You will be subject to federal and state income taxes on the taxable portion of your in-plan Roth conversion. No taxes will be with-
held on this conversion. Accordingly, your decision to convert to Roth is irrevocable. You are advised to seek the advice of a qualified
tax advisor prior to making this conversion.
5. account holdeR authoRiZation
I declare that, to the best of my belief, the information on this form is true, correct and complete. It is understood that the furnishing
of this form by OSGP does not constitute an admission that there is any benefit due to me.
Account Holder Signature
Date
Your form will NOT be processed without Signature, Date and SSN completed
Account Holder SSN
mail oR fax instRuctions
Please return the authorized in-plan Roth Conversion request to: Oregon Savings Growth Plan
800 Summer Street NE Suite 200
Salem, OR 97301
Print Form
Clear Fields
800 Summer Street N.E., Suite 200, Salem, OR 97301 / 503.378.3730 (Phone) / 503.378.5888 (Fax) /
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