Rollover Certification Form (For 60-Day Rollovers, Direct Rollovers and Conversion Rollovers)

Transcription

1 Rollover Certification Form (For 60-Day Rollovers, Direct Rollovers and Conversion Rollovers) Use this form to deposit a rollover contribution into a Fifth Third Securities IRA account. Due to recent law changes, rollover opportunities have been expanded and there are now several new ways rollover contributions can be made into IRA accounts. Refer to the charts below to determine which type of rollover applies to you and which form(s) to sign and give to your Investment Professional. For rollovers from another IRA into your Fifth Third Securities IRA account: If you are the IRA Owner or Spouse Beneficiary and you are rolling assets distributed from a SIMPLE IRA (at any time) Traditional IRA Rollover IRA SEP-IRA SIMPLE IRA (after 2-year period) into your 5/3 rd Securities SIMPLE IRA Traditional IRA Rollover IRA SEP-IRA (as a Roth Conversion) then complete this Rollover Certification Form A B For rollovers from an employer-sponsored retirement plan into your Fifth Third Securities IRA account: If you are the Plan Participant Spouse Beneficiary and you are rolling assets distributed from a(an) Employer Plan 1 Roth Employer Plan 2 Employer Plan 1 Roth Employer Plan 2 into your 5/3 rd Securities (as a Direct Roth Conversion) Traditional IRA Rollover IRA SEP-IRA or -BDA (as a Direct Roth Conversion) IRA-BDA Traditional IRA Rollover IRA SEP-IRA) -BDA Non-Spouse Beneficiary 3 Employer Plan 1 (as a Direct Roth Conversion) IRA-BDA -BDA Roth Employer Plan 2 -BDA then complete this Rollover Certification Form 1 Employer Plan: Includes a Qualified Plan under 401(a) (e.g., 401(k), pension, profit sharing and ESOPs), 403(b) plan, governmental 457(b) plan, and the Federal Employees Thrift Savings Plan. 2 Roth Employer Plan: Includes a Designated Roth Account under a 401(k) plan, 403(b) plan, governmental 457(b) plan or the Federal Employees Thrift Savings Plan. 3 Non-Spouse Beneficiary: Employer plan assets must be moved as a direct rollover. You cannot move the employer plan assets as a 60-day rollover. The direct rollover option applies only to a non-spouse beneficiary that is an individual or is a trust that meets the requirements to be a designated beneficiary within the meaning of IRC Section 401(a)(9)(E). E C E D C D E D #FTS /15 Page 1 of 9

2 Form A: 60-Day Rollover into a Traditional IRA (including a Rollover IRA or SEP-IRA), a SIMPLE IRA or a (for use by an IRA Owner or Spouse Beneficiary) Complete this form to deposit a rollover contribution in these situations: into a TRADITIONAL IRA (including a ROLLOVER IRA or SEP-IRA) or SIMPLE IRA with Fifth Third Securities, Inc. that was distributed from another IRA. into a ROTH IRA with Fifth Third Securities, Inc. that was distributed from another. IMPORTANT: Effective 01/01/2015, the IRS has restricted rollovers between IRAs to once per 12 months per individual. All Traditional, Rollover, SEP, SIMPLE and s you own are aggregated for purposes of this limit. Name: Amount:,,. ($ or shares) 60-DAY ROLLOVER CERTIFICATION I want to roll money into my Traditional IRA (including a Rollover or SEP-IRA), my SIMPLE IRA or my from another Traditional IRA (including a Rollover or SEP-IRA), SIMPLE IRA or. I am eligible to complete this rollover and all of the following statements are correct: For 60-Day Rollovers into a Traditional IRA (including a Rollover or SEP-IRA) or SIMPLE IRA: This rollover contribution is being made within 60 days after my receipt of funds from the same or another IRA, excluding a, in which I was either the participant or surviving spouse beneficiary. In the case of a distribution from my IRA due to a first time home buyer which is being rolled into this IRA because of a delay in the acquisition of the first time home, this rollover contribution is being made within 120 days after my receipt of funds from the distributing IRA. During the 12-month period prior to my receipt of the distribution being rolled over, I have not received a distribution from any IRA which was subsequently rolled over to the same or another IRA. (This rule does not apply to a delay in the acquisition of a residence for a first time homebuyer). I am not rolling over any Required Minimum Distribution (RMD) with respect to the distributing IRA plan. If this rollover contribution represents a distribution from a SIMPLE IRA and I have not participated in my employer s SIMPLE Plan for 2 years, the rollover contribution is being made to a SIMPLE IRA. For 60-Day Rollovers into a : This rollover contribution is being made within 60 days after my receipt of funds from the same or another in which I was either the participant or surviving spouse beneficiary. In the case of a distribution from my due to a first time home buyer which is being rolled into this IRA because of a delay in the acquisition of the first time home, this rollover contribution is being made within 120 days after my receipt of funds from the distributing. During the 12-month period prior to my receipt of the distribution being rolled over, I have not received a distribution from any that was subsequently rolled over to the same or another. (This rule does not apply to a delay in the acquisition of a residence for a first time homebuyer). I hereby irrevocably elect, pursuant to IRS Regulation 1.402(a)(5)-1T to treat this contribution as a rollover contribution. I understand that this will not be a valid IRA rollover unless all of the statements above are correct. I acknowledge that, due to the complexities involved in the tax treatment of eligible rollovers, Fifth Third Securities and the Custodian have recommended that I consult with my tax advisor or the Internal Revenue Service before completing this transaction to make certain that this transaction qualifies as a rollover and is appropriate in my individual circumstances. I understand rollover contributions are reported to the IRS. I hereby release Fifth Third Securities and the Custodian from any claim for damages on account of the failure of this transaction to qualify as a valid rollover. Page 2 of 9

3 Form B: Conversion Rollover from a Traditional IRA (including a Rollover IRA or SEP-IRA), or a SIMPLE IRA (for use by an IRA Owner or Spouse Beneficiary) Complete this form to deposit a conversion rollover contribution into a ROTH IRA with Fifth Third Securities, Inc. that was distributed from a Traditional IRA (including a Rollover IRA or SEP-IRA), or a SIMPLE IRA. Name: Amount:,,. ($ or shares) ROTH CONVERSION / ROLLOVER CERTIFICATION I want to roll money into my as a Roth conversion from a Traditional IRA (including a Rollover or SEP-IRA) or SIMPLE IRA. I am eligible to complete this qualified rollover contribution and all of the following statements are correct: I am eligible to complete a Roth Conversion (refer to IRS Publication 590 for details on conversion eligibility). I understand that the taxable amount of the conversion will be subject to federal income taxes in the year in which the distribution from the Traditional IRA (including a Rollover IRA or SEP-IRA), or a SIMPLE IRA occurs. This conversion rollover contribution is being made within 60 days after my receipt of funds from another IRA (excluding a ) in which I was either the participant or surviving spouse beneficiary. I am not converting any Required Minimum Distribution (RMD) amount with respect to the distributing IRA plan. If this conversion rollover contribution represents a distribution from a SIMPLE IRA, I have participated in my employer s SIMPLE Plan for at least 2 years. I hereby irrevocably elect, pursuant to IRS Regulation 1.402(a)(5)-1T to treat this contribution as a rollover contribution and authorize Fifth Third Securities, Inc. and the Custodian to make the above-request conversion contribution to my Premiere Select account. I understand that this will not be a valid rollover or Roth conversion unless all of the statements above are correct. I acknowledge that, due to the complexities involved in the tax treatment of rollovers and Roth conversions, Fifth Third Securities and the Custodian have recommended that I consult with my tax advisor or the Internal Revenue Service before completing this transaction to make certain that this transaction qualifies as a Roth conversion and is appropriate in my individual circumstances. I understand Roth conversions are reported to the IRS. I hereby release Fifth Third Securities and the Custodian from any claim for damages on account of the failure of this transaction to qualify as a valid rollover or Roth conversion. Page 3 of 9

4 Form C: Rollover/Direct Rollover from an Employer Plan into a Traditional IRA (including a Rollover IRA or SEP-IRA) or from a Roth Employer Plan into a (for use by a Plan Participant or Spouse Beneficiary) Complete this form to deposit a rollover contribution in these situations: into a TRADITIONAL IRA (including a ROLLOVER IRA or SEP-IRA) with Fifth Third Securities, Inc. that was distributed from an employer-sponsored retirement plan. into a ROTH IRA with Fifth Third Securities, Inc. that was distributed from a Designated Roth Account under an employersponsored retirement plan. Name: Amount*:,,. ($ or shares) *If the exact rollover amount from the plan is unknown at the time this form is completed, leave the Amount field, above, blank. Instead, provide the name of the distributing employer plan and the estimated dollar amount below: *Employer Plan Name: *Estimated Rollover Amount:,,. ($ or shares) ROLLOVER / DIRECT ROLLOVER CERTIFICATION I want to roll money into my Traditional IRA (including a Rollover or SEP-IRA) from my employer s retirement plan. I am eligible to complete this Rollover/Direct Rollover of an Eligible Rollover Distribution and all of the following statements are correct: My employer's qualified plan, qualified annuity, 403(b) plan, governmental 457(b) plan, or the Federal Employees Thrift Savings Plan, has made or will make an Eligible Rollover Distribution which is either being paid in a Direct Rollover to National Financial Services (NFS) as the Custodian of my Fifth Third Securities IRA, or paid directly to me which I am rolling over no later than the 60th day after receiving the Eligible Rollover Distribution. I am one of the following: o the plan participant; o the surviving spouse of the deceased plan participant; or, o the spouse or former spouse of the plan participant under a Qualified Domestic Relations Order. For rollovers into a Traditional IRA (including a Rollover IRA or SEP-IRA), the Eligible Rollover Distribution is from the employer s qualified plan, qualified annuity, 403(b) plan, governmental 457(b) plan, or from the Federal Employees Thrift Savings Plan. For rollovers into a, the Eligible Rollover Distribution is from the Designated Roth Account under the employer s 401(k) plan, 403(b) plan, governmental 457(b) plan, or from the Federal Employees Thrift Savings Plan. This Rollover/Direct Rollover does not include any Required Minimum Distributions with respect to the employer's plan. This Rollover/Direct Rollover is not part of a series of payments over my life expectancy or a period of 10 years or more. RISK CONSIDERATIONS FOR ROLLOVERS Deciding to rollover funds from an employer-sponsored retirement plan is an important decision. You should reach an investment decision only after carefully consideration and consultation with your investment, legal and tax advisors, and a determination of the suitability of a rollover in light of your particular circumstances. The following are considerations that you should discuss with them: Investment Options depending on your options in your employer s retirement plan, an IRA may enable you to select from a broader range of investment options. The importance of this factor will depend in part on how satisfied you are with your current plan investment options. For example, if you are satisfied by the low-cost institutional funds that may be available in your current plan(s), you may not regard an IRA s broader array of investments as an important factor. Fees and Expenses employer retirement plans and IRAs typically involve (i) investment-related expenses and (ii) plan or account fees. Investment-related expenses may include sales loads, commissions, the expenses of any mutual funds in which assets are invested and investment advisory fees. Plan fees typically include additional plan administrative fees (e.g., recordkeeping, compliance, trustee fees) and fees for services such as access to a customer service representative. However, in some cases, employers pay for some or all of the plan s administrative expenses. An IRA s account fees may include, for example, administrative, account set-up and custodial fees, which will all be paid by you (or your account). Page 4 of 9

5 RISK CONSIDERATIONS FOR ROLLOVERS, continued Services You may wish to consider the different levels of service available under each option. Some employer retirement plans, for example, provide access to investment advice, planning tools, telephone help lines, educational materials and workshops. Similarly, IRA providers offer different levels of service, which may include full brokerage service, investment advice, distribution planning and access to securities execution online. Penalty-Free Withdrawals If you are an employee and leave your job during or after the year you attain age 55, you may be able to take penalty-free withdrawals from your employer s retirement plan. In contrast, penalty-free withdrawals generally may not be made from an IRA until age 59½, except when the withdrawal is for a qualifying reason (such as qualified higher education expenses). It also may be easier to borrow from an employer retirement plan if the plan allows participant loans. Protection from Creditors and Legal Judgments Generally, plan assets have unlimited protection from creditors under federal law, while IRA assets have more limited protection (e.g., in bankruptcy proceedings). State laws vary in the protection of IRA assets in lawsuits. Required Minimum Distributions Once you reach the age of 70½, the rules for employer retirement plans and traditional IRAs require the periodic withdrawal of certain minimum amounts, known as the required minimum distributions. If you are still working at the age of 70½ and are not a more than 5% owner of the company, however, you may not be required to make required minimum distributions from your current employer s retirement plan. This may be advantageous if you plan to work into your 70s. For Roth accounts, the required minimum distribution rules apply to Roth accounts in employer retirement plans at age 70½, but do not apply to s until the death of the IRA owner. Employer Stock If you hold significantly appreciated employer stock in a retirement plan, you should consider the negative tax consequences of rolling the stock to an IRA. If employer stock is transferred in-kind to an IRA, any stock appreciation will be taxed as ordinary income upon distribution. In addition, the tax advantages of retaining employer stock in a non-qualified account should be balanced with the possibility that you may be excessively concentrated in employer stock. There are risks having a significant amount of employer stock in a retirement account; it may be advisable for you to liquidate the holdings and roll over the value to an IRA, even if it means losing long-term capital gains treatment on the stock s appreciation. I hereby irrevocably elect, pursuant to IRS Regulation 1.402(a)(5)-1T to treat this contribution as a rollover contribution. I understand that this will not be a valid IRA rollover unless all of the statements in the Rollover/Direct Rollover Certification section above are correct. I acknowledge that, due to the complexities involved in the tax treatment of eligible rollover distributions from qualified plans, qualified annuities, 403(b) plans, governmental 457(b) plans, or the Federal Employees Thrift Savings Plan and rollovers/direct rollovers to IRAs, Fifth Third Securities and the Custodian have recommended that I consult with my tax advisor or the Internal Revenue Service before completing this transaction to make certain that this transaction qualifies as a rollover and is appropriate in my individual circumstances. I understand rollover contributions are reported to the IRS. I hereby release Fifth Third Securities and the Custodian from any claim for damages on account of the failure of this transaction to qualify as a valid rollover. If applicable, the undersigned authorizes Fifth Third Securities, Inc. and the Custodian to commingle regular IRA contributions with rollover/direct rollover contributions. I understand that commingling regular IRA contributions with rollover/direct rollover contributions from employer plans may preclude me from rolling over funds in my rollover "conduit" IRA into another employer plan. With such knowledge, I authorize and direct Fifth Third Securities, Inc. and the Trustee/Custodian to place regular IRA contributions in my rollover "conduit" IRA or vice versa. I understand that I have the option to keep my previous employer s retirement plan at my previous employer, and I may have the option to move my previous employer s retirement plan to my new employer s retirement plan in lieu of rolling over my plan assets to an IRA. Please attach: if you are rolling assets into a, documentation from the employer plan to confirm the assets being rolled originated from a Designated Roth Account under a 401(k), 403(b), governmental 457(b) plan or the Federal Employees Thrift Savings Plan. FOR OFFICE USE ONLY: If an estimated rollover amount was provided above, complete this section when the final amount is received and forward this form and the rollover check to Brokerage Operations no later than 60 days after the client s signature date. Rep Name: Exact Amount: ($ or shares) Rep Signature: Date: Page 5 of 9

6 Form D: Rollover/Direct Rollover from an Employer Sponsored Retirement Plan into an Inherited IRA or Inherited (for use by a Spouse Beneficiary or Non-Spouse Beneficiary) Complete this form to deposit a rollover contribution in these situations: into an INHERITED IRA (known as an IRA-BDA (Beneficiary Distribution Account)) with Fifth Third Securities, Inc. that was distributed from an employer-sponsored retirement plan. into an INHERITED ROTH IRA (ROTH IRA-BDA) with Fifth Third Securities, Inc. that was distributed from a Designated Roth Account under an employer-sponsored retirement plan. NOTE: Non-spouse beneficiaries must move employer plan assets as a Direct Rollover; 60-Day Rollovers are NOT allowed. Name: Amount*:,,. ($ or shares) *If the exact rollover amount from the plan is unknown at the time this form is completed, leave the Amount field, above, blank. Instead, provide the name of the distributing employer plan and the estimated dollar amount below: *Employer Plan Name: *Estimated Rollover Amount:,,. ($ or shares) ROLLOVER / DIRECT ROLLOVER CERTIFICATION I want to roll money into my Inherited IRA from an employer-sponsored retirement plan or into my Inherited from the Designated Roth Account under an employer-sponsored retirement plan. I am eligible to complete this Rollover/Direct Rollover of an Eligible Rollover Distribution and all of the following statements are correct: I am one of the following: the surviving spouse of the deceased plan participant; a non-spouse beneficiary of a deceased plan participant or, the trustee of a trust that is the named beneficiary of the deceased plan participant where the beneficiaries of the trust meet the requirements to be designated beneficiaries within the meaning of IRC Section 401(a)(9)(E). For rollovers into an Inherited IRA (IRA-BDA), the Eligible Rollover Distribution is from the employer s qualified plan, qualified annuity, 403(b) plan, governmental 457(b) plan, or from the Federal Employees Thrift Savings Plan. For rollovers into an Inherited (-BDA), the Eligible Rollover Distribution is from the Designated Roth Account under the employer s 401(k) plan, 403(b) plan, governmental 457(b) plan, or from the Federal Employees Thrift Savings Plan. The Eligible Rollover Distribution is either being paid as a Direct Rollover to National Financial Services (NFS) as the Custodian of my Fifth Third Securities Inherited IRA / Inherited, or paid directly to me which I am depositing as a rollover contribution into my Inherited IRA / Inherited no later than the 60th day after receiving the Eligible Rollover Distribution. If I am not the surviving spouse beneficiary, the Eligible Rollover Distribution will be paid as a Direct Rollover to National Financial Services (NFS) as the Custodian of my Fifth Third Securities IRA-BDA / -BDA. This Rollover/Direct Rollover does not include any Required Minimum Distributions with respect to the employer's plan. This Rollover/Direct Rollover is not part of a series of payments over my life expectancy or a period of 10 years or more. RISK CONSIDERATIONS FOR ROLLOVERS Deciding to rollover funds from an employer-sponsored retirement plan is an important decision. You should reach an investment decision only after carefully consideration and consultation with your investment, legal and tax advisors, and a determination of the suitability of a rollover in light of your particular circumstances. The following are considerations that you should discuss with them: Investment Options depending on your options in your employer s retirement plan, an IRA may enable you to select from a broader range of investment options. The importance of this factor will depend in part on how satisfied you are with your current plan investment options. For example, if you are satisfied by the low-cost institutional funds that may be available in your current plan(s), you may not regard an IRA s broader array of investments as an important factor. Page 6 of 9

7 RISK CONSIDERATIONS FOR ROLLOVERS, continued Fees and Expenses employer retirement plans and IRAs typically involve (i) investment-related expenses and (ii) plan or account fees. Investment-related expenses may include sales loads, commissions, the expenses of any mutual funds in which assets are invested and investment advisory fees. Plan fees typically include additional plan administrative fees (e.g., recordkeeping, compliance, trustee fees) and fees for services such as access to a customer service representative. However, in some cases, employers pay for some or all of the plan s administrative expenses. An IRA s account fees may include, for example, administrative, account set-up and custodial fees, which will all be paid by you (or your account). Services You may wish to consider the different levels of service available under each option. Some employer retirement plans, for example, provide access to investment advice, planning tools, telephone help lines, educational materials and workshops. Similarly, IRA providers offer different levels of service, which may include full brokerage service, investment advice, distribution planning and access to securities execution online. Penalty-Free Withdrawals If If you are an employee and leave your job during or after the year you attain age 55, you may be able to take penalty-free withdrawals from your employer s retirement plan. In contrast, penalty-free withdrawals generally may not be made from an IRA until age 59½, except when the withdrawal is for a qualifying reason (such as qualified higher education expenses). It also may be easier to borrow from an employer retirement plan if the plan allows participant loans. Protection from Creditors and Legal Judgments Generally, plan assets have unlimited protection from creditors under federal law, while IRA assets have more limited protection (e.g., in bankruptcy proceedings). Inherited IRA assets do not have protection from creditors under federal law. State laws vary in the protection of IRA and inherited IRA assets in lawsuits. Required Minimum Distributions Once you reach the age of 70½, the rules for employer retirement plans and traditional IRAs require the periodic withdrawal of certain minimum amounts, known as the required minimum distributions. If you are still working at the age of 70½ and are not a more than 5% owner of the company, however, you may not be required to make required minimum distributions from your current employer s retirement plan. This may be advantageous if you plan to work into your 70s. For Roth accounts, the required minimum distribution rules apply to Roth accounts in employer retirement plans at age 70½, but do not apply to s until the death of the IRA owner. Employer Stock If you hold significantly appreciated employer stock in a retirement plan, you should consider the negative tax consequences of rolling the stock to an IRA. If employer stock is transferred in-kind to an IRA, any stock appreciation will be taxed as ordinary income upon distribution. In addition, the tax advantages of retaining employer stock in a non-qualified account should be balanced with the possibility that you may be excessively concentrated in employer stock. There are risks having a significant amount of employer stock in a retirement account; it may be advisable for you to liquidate the holdings and roll over the value to an IRA, even if it means losing long-term capital gains treatment on the stock s appreciation. I hereby irrevocably elect, pursuant to IRS Regulation 1.402(a)(5)-1T to treat this contribution as a rollover contribution. I understand that this will not be a valid IRA rollover unless all of the statements in the Rollover/Direct Rollover Certification section above are correct.. I acknowledge that, due to the complexities involved in the tax treatment of eligible rollover distributions from qualified plans, qualified annuities, 403(b) plans, governmental 457(b) plans, or the Federal Employees Thrift Savings Plan and rollovers/direct rollovers to IRAs, Fifth Third Securities and the Custodian have recommended that I consult with my tax advisor or the Internal Revenue Service before completing this transaction to make certain that this transaction qualifies as a rollover and is appropriate in my individual circumstances. I understand rollover contributions are reported to the IRS. I hereby release Fifth Third Securities and the Custodian from any claim for damages on account of the failure of this transaction to qualify as a valid rollover. Please attach: documentation from the employer plan to confirm the payment was made to you, as the beneficiary of a deceased plan participant. if you are rolling assets into a inherited, documentation from the employer plan to confirm the assets being rolled originated from a Designated Roth Account under a 401(k), 403(b), governmental 457(b) plan or the Federal Employees Thrift Savings Plan. FOR OFFICE USE ONLY: If an estimated amount was provided above, complete this section when the final amount is received and forward this form and the rollover check to Brokerage Operations no later than 60 days after the client s signature date. Rep Name: Exact Amount: ($ or shares) Rep Signature: Date: Page 7 of 9

8 Form E: Direct Roth Conversion from an Employer Sponsored Retirement Plan into a or Inherited (for use by a Plan Participant, Spouse Beneficiary or Non-Spouse Beneficiary) Complete this form to deposit a conversion rollover contribution in these situations: into an ROTH IRA with Fifth Third Securities, Inc. that was distributed from an employer-sponsored retirement plan. Applies only to a Plan Participant or Spouse Beneficiary. into an INHERITED ROTH IRA (ROTH IRA-BDA) with Fifth Third Securities, Inc. that was distributed from an employersponsored retirement plan. Applies only to a Spouse Beneficiary or Non-Spouse Beneficiary. NOTE: Non-spouse beneficiaries must move employer plan assets as a Direct Rollover; 60-Day Rollovers are NOT allowed. Name: Amount*:,,. ($ or shares) *If the exact rollover amount from the plan is unknown at the time this form is completed, leave the Amount field, above, blank. Instead, provide the name of the distributing employer plan and the estimated dollar amount below: *Employer Plan Name: *Estimated Rollover Amount:,,. ($ or shares) ROTH CONVERSION / ROLLOVER CERTIFICATION I want to convert money from my employer s retirement plan directly into my or, if I am a beneficiary of a deceased plan participant, into my Inherited (-BDA). I am eligible to make this qualified rollover contribution and all of the following statements are correct: For qualified rollover contributions into a For qualified rollover contributions into an Inherited (-BDA) I am one of the following: I am one of the following: the plan participant; the surviving spouse of a deceased plan participant; the surviving spouse of a deceased plan participant; or, or, a non-spouse beneficiary of a deceased plan the spouse or former spouse of a plan participant under a Qualified Domestic Relations Order. participant My employer's qualified plan, qualified annuity, 403(b) plan, governmental 457(b) plan, or the Federal Employees Thrift Savings Plan, has made or will make an Eligible Rollover Distribution which is either being paid as a direct qualified rollover contribution to National Financial Services (NFS) as the Custodian of my Fifth Third Securities / Roth IRA-BDA, or paid directly to me which I am depositing as a qualified rollover contribution into my / - BDA no later than the 60th day after receiving the Eligible Rollover Distribution. If I am a non-spouse beneficiary, the Eligible Rollover Distribution will be paid as a direct qualified rollover contribution to National Financial Services (NFS) as the Custodian of my Fifth Third Securities -BDA. I am eligible to complete a Roth Conversion (refer to IRS Publication 590 for details on conversion eligibility). I understand that the taxable amount of the conversion will be subject to federal income taxes in the year in which the distribution from the employer plan occurs. This Roth conversion rollover does not include any Required Minimum Distributions with respect to the employer's plan. This Roth conversion rollover is not part of a series of payments over my life expectancy or a period of 10 years or more. RISK CONSIDERATIONS FOR ROLLOVERS Deciding to rollover funds from an employer-sponsored retirement plan is an important decision. You should reach an investment decision only after carefully consideration and consultation with your investment, legal and tax advisors, and a determination of the suitability of a rollover in light of your particular circumstances. The following are considerations that you should discuss with them: Investment Options depending on your options in your employer s retirement plan, an IRA may enable you to select from a broader range of investment options. The importance of this factor will depend in part on how satisfied you are with your current plan investment options. For example, if you are satisfied by the low-cost institutional funds that may be available in your current plan(s), you may not regard an IRA s broader array of investments as an important factor. Page 8 of 9

9 RISK CONSIDERATIONS FOR ROLLOVERS, continued Fees and Expenses employer retirement plans and IRAs typically involve (i) investment-related expenses and (ii) plan or account fees. Investment-related expenses may include sales loads, commissions, the expenses of any mutual funds in which assets are invested and investment advisory fees. Plan fees typically include additional plan administrative fees (e.g., recordkeeping, compliance, trustee fees) and fees for services such as access to a customer service representative. However, in some cases, employers pay for some or all of the plan s administrative expenses. An IRA s account fees may include, for example, administrative, account set-up and custodial fees, which will all be paid by you (or your account). Services You may wish to consider the different levels of service available under each option. Some employer retirement plans, for example, provide access to investment advice, planning tools, telephone help lines, educational materials and workshops. Similarly, IRA providers offer different levels of service, which may include full brokerage service, investment advice, distribution planning and access to securities execution online. Penalty-Free Withdrawals If you are an employee and leave your job during or after the year you attain age 55, you may be able to take penalty-free withdrawals from your employer s retirement plan. In contrast, penalty-free withdrawals generally may not be made from an IRA until age 59½, except when the withdrawal is for a qualifying reason (such as qualified higher education expenses). It also may be easier to borrow from an employer retirement plan if the plan allows participant loans. Protection from Creditors and Legal Judgments Generally, plan assets have unlimited protection from creditors under federal law, while IRA assets have more limited protection (e.g., in bankruptcy proceedings). Inherited IRA assets do not have protection from creditors under federal law. State laws vary in the protection of IRA and inherited IRA assets in lawsuits. Required Minimum Distributions Once you reach the age of 70½, the rules for employer retirement plans and traditional IRAs require the periodic withdrawal of certain minimum amounts, known as the required minimum distributions. If you are still working at the age of 70½ and are not a more than 5% owner of the company, however, you may not be required to make required minimum distributions from your current employer s retirement plan. This may be advantageous if you plan to work into your 70s. For Roth accounts, the required minimum distribution rules apply to Roth accounts in employer retirement plans at age 70½, but do not apply to s until the death of the IRA owner. Employer Stock If you hold significantly appreciated employer stock in a retirement plan, you should consider the negative tax consequences of rolling the stock to an IRA. If employer stock is transferred in-kind to an IRA, any stock appreciation will be taxed as ordinary income upon distribution. In addition, the tax advantages of retaining employer stock in a non-qualified account should be balanced with the possibility that you may be excessively concentrated in employer stock. There are risks having a significant amount of employer stock in a retirement account; it may be advisable for you to liquidate the holdings and roll over the value to an IRA, even if it means losing long-term capital gains treatment on the stock s appreciation. I hereby irrevocably elect, pursuant to IRS Regulation 1.402(a)(5)-1T to treat this contribution as a rollover contribution and authorize Fifth Third Securities, Inc. and the Custodian to make the above-request conversion contribution to my Premiere Select account. I understand that this will not be a valid rollover or Roth conversion unless all of the statements in the Rollover/Direct Rollover Certification section above are correct. I acknowledge that, due to the complexities involved in the tax treatment of eligible rollover distributions from qualified plans, qualified annuities, 403(b) plans, governmental 457(b) plans, or the Federal Employees Thrift Savings Plan and Roth conversions, Fifth Third Securities and the Custodian have recommended that I consult with my tax advisor or the Internal Revenue Service before completing this transaction to make certain that this transaction qualifies as a Roth conversion and is appropriate in my individual circumstances. I understand Roth conversions are reported to the IRS. I hereby release Fifth Third Securities and the Custodian from any claim for damages on account of the failure of this transaction to qualify as a valid rollover or Roth conversion. FOR OFFICE USE ONLY: If an estimated amount was provided above, complete this section when the final amount is received and forward this form and the rollover check to Brokerage Operations no later than 60 days after the client s signature date. Rep Name: Exact Amount: ($ or shares) Rep Signature: Date: Page 9 of 9