Incoming Account Transfer/Exchange/ Direct Rollover (Qualified Accounts Only) for Ameriprise certificates and Riversource annuities.

Transcription

1 CED Amerprse Fnancal Servces, Inc Amerprse Fnancal Center Mnneapols, MN Incomng Account Transfer/Exchange/ Drect Rollover (Qualfed Accounts Only) for Amerprse certfcates and Rversource annutes.! Ths form s not elgble for electronc submsson. Please mal sgned orgnal to Home Offce. For further nformaton, call If requred felds are unknown, contact the delverng frm. Ths form can be used to transfer or rollover assets n an ndvdual retrement or qualfed plan account from another fnancal nsttuton. Crtcal: All requests to transfer nto Columba fund accounts endng n 002 wll be rejected. Attach a copy of your most recent statement dated wthn the last 90 days. To roll over assets from a 401(k) or other qualfed employer-sponsored plan, please consult your employer for requrements pror to submttng ths form. For certfcates only: For thrd party frms who requre ther own form, submt the thrd party transfer paperwork n addton to ths form. Socal Securty Number To transfer a certfcate to a Brokerage account, use eforms - Account Transfer. Use Form 3057 for Non-Qualfed Certfcate Transfers. Use Form for a Transfer, Rollover or Exchange nto a RverSource annuty held n a brokerage account (Prefx 9925). Use Form for a 1035 Exchange nto all other RverSource annutes or nsurance polces for Lfe and Annuty. Part 1 Amerprse Fnancal Servces, Inc. or RverSource Lfe Insurance Company Account Regstraton Account Owner Name Ttle of Account Type of Account You Are Movng To: Tradtonal IRA SIMPLE IRA CESA (not avalable n Annutes) 403(b)/TSA Rollover IRA Inherted IRA Proft Sharng Plan 403(b)/TSCA SEP IRA Roth IRA Money Purchase Plan Part 2 Delverng Frm Informaton Account Owner's Name Ttle of Account as shown on your ment Type of Account You are Movng From: Tradtonal IRA SIMPLE IRA CESA 403(b)/TSA Rollover IRA Inherted IRA Proft Sharng Plan 403(b)/TSCA SEP IRA Roth IRA Money Purchase Plan (k) Roth Feature 401(k) Other: Delverng Frm Informaton contnued on next page... Sgn on Page(s) 4, 5 The orgnal form must be maled for processng Amerprse Fnancal, Inc. All rghts reserved Page 1 of 5

2 CED Delverng Frm Informaton contnued Are you movng from an Annuty? Yes No Contract Lost Contract Attached Company Informaton Name of Company currently holdng your account Part 3 Plan Sponsor Informaton (Requred for 403(b)/TSA-TSCA accounts only) Recevng Plan Sponsor Name/Current Employer Employer Identfcaton Number (EIN) Dstrbutng Plan Sponsor Name/Former Employer (f dfferent) Employer Identfcaton Number (EIN) Thrd Party Admnstrator (TPA) Name If you are currently retred, unemployed, or workng for an employer who does not sponsor a 403(b)/TSA-TSCA program, your 403(b)/TSA-TSCA account s deemed assocated wth your most recent employer who sponsored the 403(b)/TSA-TSCA arrangement.! Note: If you are age 70½ or older, you may have a Requred Mnmum Dstrbuton (RMD) requrement Page 2 of 5

3 CED Part 4 Instructons to Fnancal Insttuton (Requred) Transfer Tax Wthholdng Instructons (Select One): (For Roth conversons only) Drect Rollover (ths s reportable to the IRS) Converson to a Roth IRA (ths s reportable to the IRS) Any amount wthheld wll be consdered a dstrbuton n the form of wthholdng and wll decrease the amount that s rolled over to the Roth IRA. If the amount wthheld s to be rolled over to the Roth IRA, the amount wthheld wll have to be made up from other assets. Federal Wthholdng: You are lable for federal ncome tax on the taxable porton of your dstrbuton. If total wthholdng s not adequate, you may be subject to estmated tax payments and/or penaltes. Wthholdng: Wthholdng rules vary by state. Clents may have the opton to: (1) opt-out of wthholdng, (2) elect default state tax wthholdng, or (3) ncrease the rate of wthholdng. Dependng on the state, state tax wthholdng could be mandatory, optonal, unavalable, or the clent may need to complete a state-specfc form. tax wthholdng may not be avalable wth all fnancal nsttutons. For state tax wthholdng rules, contact them drectly. Please note that taxes wthheld per your electons or n accordance wth state rules wll not be refunded. Dfferent wthholdng rules apply n certan stuatons: If we do not have a vald Taxpayer Identfcaton Number on the account, f the payment s delvered outsde the Unted s or f you are a non-resdent alen. For a Qualfed Plan or a 403(b)/TSA-TSCA to a Roth IRA: A drect converson from a Qualfed Plan or 403(b)/TSA-TSCA to a Roth IRA results n ncome tax beng due on the taxable porton of the transacton. Please see the Specal Tax Notce provded by the plan sponsor of your Qualfed Plan or 403(b)/TSA-TSCA plan. You should consult wth a tax advsor pror to requestng ths transacton. There wll be no wthholdng on ths request unless you elect wthholdng below. For Tradtonal, SEP, or Smple IRA to a Roth IRA 10 federal ncome tax wll be wthheld from the converson amount unless you make a dfferent wthholdng electon below. Amounts dstrbuted n the form of wthholdng may result n a 10 IRS premature penalty tax n addton to the ordnary taxes that apply to the entre dstrbuton amount. Consult wth a tax advsor f you elect to wthhold. Federal Wthholdng Do not wthhold federal tax Wthhold 10 federal tax Wthhold federal tax - must be more than 10 Wthholdng Do not wthhold state tax Wthhold default state tax Wthhold state tax Lqudaton Instructons (You must select A, B, or C) A. Brokerage Lqudaton Instructons (the clent may need to call to lqudate the account) Lqudate (sell) all postons and transfer entre account as cash. Partal lqudaton. Please lst specfc asset amount(s) or percent(s) below. B. Annuty Lqudaton Instructons Lqudate annuty mmedately and transfer cash. I am aware of and acknowledge any penalty and/or surrender charges I wll ncur from an early wthdrawal. Lqudate annuty at maturty and transfer cash. Specfy Maturty Date: (Submt 3 weeks pror to Maturty Date) Partal lqudaton. Please lst specfc asset amount(s) or percent(s) below. C. Certfcate of Depost Lqudaton Instructons Lqudate CD mmedately and transfer cash. I am aware of and acknowledge any penalty I wll ncur from an early wthdrawal. Lqudate CD at maturty and transfer cash. Specfy Maturty Date: Partal lqudaton. Please lst specfc asset amount(s) or percent(s) below. (Submt 3 weeks pror to Maturty Date) Account Number and/or Plan Name Specfc Amount or Percent Make checks payable to: For Certfcates: Amerprse Fnancal Servces, Inc. Attn: Account Transfers Amerprse Fnancal Center Mnneapols, MN Please reference clent's name and account number on all checks. For Annutes: RverSource Lfe Insurance Company Attn: Account Transfers Amerprse Fnancal Center Mnneapols, MN Page 3 of 5

4 CED Part 5 Investment Instructons to Amerprse Fnancal Servces, Inc. or RverSource Lfe Insurance Company Account Number and/or Plan Name (Plan name s requred for new accounts) Specfc Amount or Percent Part 6 Clent Sgnature and Acknowledgement As used below, the word I refers to the applcant who s the taxpayer on the account. I understand that account(s) to be opened for me at Amerprse Fnancal Servces, Inc. may be restrcted untl an executed applcaton s receved. I further understand that f an executed applcaton s not receved wthn 45 days of account openng, those restrctons wll nclude a prohbton on new purchase transactons and the depost or transfer n of cash or securtes. I acknowledge recept of and consent to all terms and condtons contaned n the Amerprse Brokerage Clent Agreement and the Other Important Dsclosures documents. I also acknowledge recept of nformaton relatng to the thrd-party cash sweep program offered by Amerprse Fnancal. I authorze my current custodan, nsurance company or trustee to execute, and release all status updates on, the above transacton to Amerprse Fnancal Servces, Inc. and RverSource Lfe Insurance Company. I am aware of and acknowledge any penalty and/or surrender charges I wll ncur from an early wthdrawal. If ths s a request for a 403(b)/TSA-TSCA account transfer or exchange, then I certfy that I am aware of the rules and requrements regardng 403(b)/TSA-TSCA account transfers and exchanges, and have had the opportunty to consult wth my personal tax advsor regardng ths transacton. I further acknowledge that I may need to request that my employer enter nto an nformaton sharng agreement or other necessary documentaton wth Amerprse Fnancal n order to mantan the Tax-Qualfed status of my 403(b)/TSA-TSCA account. Account Owner Name Account Owner Sgnature Co-Account Owner/Communty Property Name Co-Account Owner/Communty Property Sgnature (f applcable) Plan Sponsor/Plan Admnstrator Name (f applcable) Plan Sponsor/Plan Admnstrator Entty Name Plan Sponsor/Plan Admnstrator Sgnature (f applcable) Servcng Advsor Name Advsor Number Extenson Page 4 of 5

5 CED Letter of Acceptance - For Corporate Use Only Amerprse Fnancal Servces, Inc. or RverSource Lfe Insurance Company wll depost assets receved n an IRA for the beneft of the above plan partcpant. Amerprse Fnancal Servces, Inc. and RverSource Lfe Insurance Company are qualfed under applcable Treasury regulatons to act as the custodan of IRA. Amerprse Fnancal Servces, Inc. or RverSource Lfe Insurance Company wll depost assets receved n a Qualfed 401(a) Plan or 403 (b)/tsa-tsca plan for the beneft of the above plan partcpant. Amerprse Fnancal Servces, Inc. and RverSource Lfe Insurance Company are qualfed under applcable Treasury regulatons to act as the custodan of the plan. Acceptance for Amerprse Fnancal Servces, Inc. or RverSource Lfe Insurance Company: Assstant Secretary (Corporate offce sgnature only) Page 5 of 5