MR./ MRS./ MS. FIRST NAME LAST NAME - Capital One

REQUEST FOR A TRANSFER OR DIRECT ROLLOVER

This form is being used to complete a:

Traditional IRA transfer to a Capital One 360 Traditional IRA Employer Plan [401(k), 403(b) or other] direct rollover to a Capital One 360 Traditional IRA

Roth IRA transfer to a Capital One 360 Roth IRA

Employer Plan [401(k), 403(b) or other] direct rollover to a Capital One 360 Roth IRA

Simple IRA transfer to a Capital One 360 Traditional IRA Note: Please consult a tax professional to

your eligibility for a direct rollover of

your Employer Plan.

Your Name and Address

MR./ MRS./ MS.

FIRST NAME

Social Security Number

CITY

Date of Birth

LAST NAME

ADDRESS

ADDRESS

STATE

ZIP

Daytime Phone

Capital One 360 IRA Savings Account Number

Who is presently holding your account?

TRUSTEE, CUSTODIAN OR INSURANCE CARRIER

ACCOUNT OR POLICY NUMBER

PLAN NAME (if applicable)

PHONE NUMBER

TRUSTEE/CUSTODIAN ADDRESS

CITY

STATE

ZIP

Instructions to Current Trustee/Custodian

Please liquidate the plan balance, in the amount shown below, and make a check payable to:

Capital One 360 fbo___________________________.

(Customer Name)

Mail the check to the address listed on the reverse side of this form.

Please include the Customer's Account Number _________________________________ on the check, or include a copy of this form.

(Capital One 360 IRA Account Number)

Amount to be rolled over or transferred

Process the rollover/transfer:

Note: Capital One 360 does not accept rollovers in kind. Liquidate and directly rollover/transfer $_________ of my account Liquidate and directly rollover/transfer all of my account

Immediately On the maturity date of ________________________________

Page 1 of 2

REQUEST FOR A TRANSFER OR DIRECT ROLLOVER

Customer Signature

Note: If you are age 70 1/2 or older, and are required to take a minimum distribution, you may not transfer or rollover the amount of your required minimum distribution to Capital One 360. By requesting this transfer or direct rollover from the plan indicated above, ? I'm certifying that all of the information provided is correct and that the funds being transferred or rolled over are eligible to be deposited into

the Capital One 360 IRA I've indicated. ? I'm acknowledging that all funds being transferred or rolled over are subject to all applicable Federal and State laws and regulations, the

Individual Retirement Account Custodial Agreement, and the IRA Savings Account Terms and Conditions. ? I accept responsibility for this transaction, and I will hold neither the Plan Administrator of the distributing plan nor Capital One 360 (including any

of its affiliates) liable for any adverse consequences arising from my request.

____________________________________________________________ _________________

(IRA Holder)

(Date)

____________________________________________________________ _________________

(Signature Guarantee [if required by current institution] )

(Date)

What's Next

Please mail this form to Capital One 360 at the address listed below. Capital One 360 will use this form to request your funds.

Your current institution may require a signature guarantee on this form, or may have additional requirements before releasing your funds. To avoid delays, please contact them before submitting this request to Capital One 360.

Your deposit will be put in the IRA Savings Account you have specified on the reverse side of this form. If you want to use this deposit for an IRA CD, please visit after we have received the funds. We will post the deposit as soon as we receive it. If you have questions about the status of your rollover or transfer, please contact the transferring institution.

Capital One 360 Acceptance

The person named above has an IRA with Capital One 360, and Capital One 360 agrees to accept the transfer or direct rollover of the funds indicated.

____________________________________________________________ _________________

(Capital One 360 Authorized Representative)

(Date)

Mail to: Capital One 360 P.O. Box 60 St. Cloud, MN 56302 Phone: 877-955-8700

Overnight Mail Address: Capital One 360 30 7th Avenue South St. Cloud, MN 56301

Page 2 of 2

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download