IRA ESA Rollover Certification

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WellsTrade IRA/ESA Rollover Certification
Customer Information (Indicate plan type)
Traditional IRA
Name

®

Roth IRA Plan

Education Savings Account
Social Security Number Date of Birth

Address

City

State

ZIP Code

Rollover Qualification (Complete A, B, C, or D) A. Traditional IRA to a Traditional IRA Rollover
1) Are the funds or property you received being deposited within 60 calendar days? 2) Is this the first distribution from the same IRA rolled over in the past 12 months? 3) If you are over age 70½, have you satisfied your minimum distribution requirement? Yes Yes Yes No No No

B. Roth IRA to a Roth IRA Rollover
1) Are the funds or property you received being deposited within 60 calendar days? 2) Is this the first distribution from the same IRA rolled over in the past 12 months? Yes Yes No No

C. Education Savings Account to an Education Savings Account Rollover
1) Are the funds or property you received being deposited within 60 calendar days? 2) Is this the first distribution from the same IRA rolled over in the past 12 months? 3) Are the funds being deposited into an ESA for the same individual in which the distributing ESA was registered, or that individual's children/stepchildren/siblings and their descendants, parents/grandparents/step-parents or a spouse of one of the foregoing? Yes Yes No No

Yes

No

D. Rollover or Direct Rollover from a Qualified Plan into a Traditional IRA
1) Are you an eligible participant (participant, spouse beneficiary or former spouse due to divorce)? 2) Did you receive these funds from an eligible qualified retirement plan? 3) If you are over age 70½, have you satisfied your minimum distribution requirement? 4) Does the rollover consist only of funds or property distributed from the qualified plan or the proceeds from the sale of property distributed from the qualified plan? 5) Are all the funds included eligible to be rolled over (see back of this form for further information)? Yes Yes Yes Yes Yes No No No No No

If you have answered "NO" to any applicable questions above, then you should not proceed with this rollover transaction. There are likely reasons that your contribution is not qualified to be rolled over into an IRA. Please consult your professional tax advisor prior to completing your rollover.
Agreement I have read and understand the rollover rules and conditions on both sides of this form and I have met the requirements for making a rollover contribution. Due to the important tax consequences of rolling over funds or property to an IRA or ESA, I understand that I should seek guidance from a professional tax advisor. I understand that Wells Fargo Bank cannot and has not provided tax advice. I release, indemnify and hold Wells Fargo Bank harmless against any liabilities I may incur as a result of this transaction. By signing this agreement, I understand that I have irrevocably designated this contribution as a rollover contribution.

Customer's Signature

Date

Signature of Custodian or Witness
Investment and Insurance Products: Not Insured by FDIC or any Federal Government Agency May Lose Value

Date

Not a Deposit of or Guaranteed by a Bank or Any Bank Affiliate

Wells Fargo Advisors, LLC is a registered broker-dealer and separate non-bank affiliate of Wells Fargo & Company
588193 Page 1 of 2

General Information Regarding Rollovers Rules and Conditions
A rollover is a way to move money or property from one eligible retirement plan (Traditional IRA, Roth IRA, Education Savings Account, Qualified Retirement Plan) to another eligible retirement plan. The Internal Revenue Code (IRC) limit show many rollovers may be taken, how quickly rollovers must be completed and how the Custodian/Trustee must report the transaction. By completing this form, you are certifying to the Custodian/Trustee that you are aware of and have satisfied the rules & conditions applicable to this transaction. Timeliness The funds/assets you receive from the distributing Retirement Plan must be deposited into an eligible IRA or ESA within 60 calendar days from the day you receive them. There are no exceptions to the 60 day rule. Frequency of Rollovers Twelve month restriction - certain IRA plans limit rollover transactions to one rollover distribution per year per IRA (Traditional IRAs, Roth IRAs and Education Savings Accounts). Twelve (12) months must pass after receipt of one rollover distribution from an IRA plan before any additional distribution from that same plan is eligible for rollover. The focus is on rollover distributions out of an IRA plan. Required Minimum Distributions Certain retirement plans require that minimum distributions are made from the plan beginning the year in which the participant turns age 70½. If this rollover is made during or after the year in which you turn age 70½, you cannot rollover any distribution to the extent that it is a required minimum distribution from the distributing plan. Eligible Persons Education Savings Account - a distribution from an ESA may be rolled over to another ESA for the benefit of the same child designee or a family member designee. Family member is defined as a son or daughter, or a descendant of either; a step-child; a sibling or step-brother or step-sister; the mother or father, or an ancestor of either; a step-father or step-mother, a son or daughter of a brother or sister; a brother or sister of the father or mother; a son-in-law, daughter-in-law, father-in-law, mother-in-law, brother-in-law, or sister-in-law, or the spouse of any of these family members. Qualified Retirement Plans - an eligible person is defined as the plan participant, the surviving spouse beneficiary of a deceased participant, or the alternate payee identified in a Qualified Domestic Relations Order (QDRO). Eligible Plans Rollover contributions may only be made to eligible plans. Distributions from a certain plan (Traditional, Roth, Education and Qualified Retirement Plan) may be rolled over to a like plan. In addition, distributions from Traditional IRAs may be rolled over to a Roth IRA or to a Qualified Retirement Plan and distributions from a Qualified Retirement Plan may be rolled over to a Traditional IRA. Distributions from a qualified plan are eligible for roll over only when the distribution is made from an eligible plan. An eligible plan is one that is qualified under IRC Section 401 (a), 403 or 457. Eligible plans include defined benefit plans, profit sharing plans, money purchase plans, 401(k) plans, tax sheltered annuities, certain governmental plans and employee stock ownership plans. Eligible Deposits Qualified plan distributions - if property other than cash is distributed, only the same property or the proceeds from the sale may be rolled over. Also, if employee non-deductible contributions are rolled over to your traditional IRA to such amounts may not be rolled.

YOU SHOULD CONSULT WITH A PROFESSIONAL TAX ADVISOR BEFORE MAKING A ROLLOVER CONTRIBUTION TO ANY IRA OR ESA
WellsTrade® - Submit your completed form to: Wells Fargo Advisors, Attention: H0004-014, PO Box 66535, St. Louis, MO 63166-9954, or Fax to 800-433-0738 Should you reqire assistance with this form, please call 1-800-TRADERS (1-800-872-3377)
588193 Page 2 of 2

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