Roth IRA Direct Rollover/Conversion Request - Not Imprinted #30514

This form is used to authorize the direct rollover/conversion of assets from a workplace retirement plan to a Roth IRA. It is a direct rollover if the assets are being moved from a Designated Roth Account (a Roth 401(k) or 403(b) plan) to a Roth IRA. It is a direct conversion if the assets are being moved from a workplace retirement plan other than a Designated Roth Ac­count to a Roth IRA. This form has a section that is completed by the Roth IRA trustee/custodian to accept the funds. Imprint­ing includes up to 4 lines of type (black ink). Two-part, one-sided, black ink, 8˝ x 11. Not Imprinted Quantity: 0 50 (37.00) 100 (63.00) 250 (130.00) 500 (181.00) 1000 (281.00) 2000 (562.00) 3000 (843.00) 4000 (1,124.00)