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22
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1
FULL NAME
*
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2
EMAIL
*
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example@example.com
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3
TRADITIONAL/SEP IRA ACCOUNT NUMBER
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4
PHONE NUMBER
*
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Please enter a valid phone number.
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5
ROTH IRA ACCOUNT NUMBER (IF AVAILABLE)
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6
What would you like to convert?
*
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Cash
Assets
Both
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7
How much would you like to convert?
*
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All Available Cash
Exact Amount
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8
CONVERT EXACTLY $
*
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9
ASSET
*
This field is required.
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10
APPRAISAL VALUE $
*
This field is required.
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11
Would you like to convert any more assets?
*
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No more Assets
One More Asset
Two more Assets
Three More Assets
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12
ASSET
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13
APPRAISAL VALUE $
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14
ASSET
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15
APPRAISAL VALUE $
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16
ASSET
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17
APPRAISAL VALUE $
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18
The IRS requires a federal tax withholding of 10% of funds being converted to a Roth IRA unless you instruct IRA Club otherwise. If a taxpayer uses IRA funds to pay taxes on the conversion, there may be an early withdrawal penalty on the pre-tax funds if you are not at least 59 ½ years old. The IRS treats this as a withdrawal from the IRA, and the taxpayer will owe income tax..
*
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DO NOT WITHHOLD 10% Federal Tax. I intend to pay taxes on the conversion with funds outside the IRA,
I intend to pay the tax on the conversion with funds from the above captioned IRA. Please withhold from
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19
CONVERSION INSTRUCTIONS
*
This field is required.
Close the IRA after the conversion.
Keep the IRA open after the conversion. *Must maintain a $500 minimum balance.
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20
Select a payment method for your processing fees
*
This field is required.
CREDIT CARD ON FILE
NEW CREDIT CARD
ACCOUNT CASH BALANCE
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21
Thank you for submitting your credit card information. Please disregard the error message below and click NEXT.
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22
Date
*
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-
Date
Year
Month
Day
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23
Signature
*
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Clear
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