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Traditional IRA Direct Rollover Request - Imprinted # 10547

This form is used to authorize the direct rollover of assets from a workplace retirement plan to a Traditional IRA. It is designed to help individuals avoid the 20% federal income tax withholding requirement applicable to certain retirement plan distributions by directly rolling over the funds to a Traditional IRA. This form has a section that is completed by the IRA trustee/custodian to accept the funds. Imprinting includes up to 4 lines of tyhhpe (black ink). Two-part, one-sided, black ink, 8 1/2 x 11.