This form is used when accepting a rollover/conversion deposit to a Roth IRA from a workplace retirement plan, a Traditional IRA or a Roth IRA. It documents the source of the deposit, whether the deposit is a rollover or a conversion and provides the means for the accountholder to comply with the require­ment that a written election be made at the time of making a rollover deposit. Imprinting includes up to 4 lines of type (black ink). Two-part, one-sided, black ink, 8½ x 11.