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Traditional IRA Rollover Election - Imprinted # 10543

This form is used when a Traditional IRA is accepting a rollover deposit from an IRA or workplace retirement plan. It documents the source of the rollover deposit. It also provides the means for the accountholder to comply with the IRS requirement that an irrevocable, written election be made at the time of making a rollover deposit. A general qualification section is included on the front of the form. Imprinting includes up to 4 lines of tyhhpe (black ink). Two-part, one-sided, black ink, 8 1/2 x 11.