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Rollover Certification Form
• Document your rollover contribution to Midland Trust (take receipt of the assets for up to 60 days before reinvesting in a new retirement plan).
• Document your direct rollover contribution (move assets directly from your qualified retirement plan to a new retirement plan).
This form documents the rollover of your asset to Midland Trust
. MIDLAND TRUST WILL NOT INITIATE THE ROLLOVER. Contact your
current custodian to roll over your assets to Midland Trust
. For multiple transactions, please use a separate form for each. Use this form to:
Mr. Ms. Mrs. Dr.
Social Security Number
Legal Address Midland Account Number
Name of Custodian/Trustee Account Number
Type of Plan you are rolling over from:
Traditional Roth SEP SIMPLE ESA HSA401K Other (PS, MP, DB, 403(b), 457)
ROLLOVER DETAILS (Market fluctuations and/or administrative fees may impact the amount received)
Indirect RolloverDirect Rollover
I am an eligible person to perform this transaction: (Select one)
Spouse beneficiary of account
Non-spouse beneficiary of account Responsible Individual Ex-spouse of account due to divorce/legal separation
ROLLOVER INSTRUCTIONS TO RESIGNING CUSTODIAN
To rollover CASH, please follow the instruction below. Contact our office for wire instructions.
Cash: Please make check payable to: Midland Trust Company (Reference Client Name & Account Number on the Check)
To roll over INVESTMENTS (Private Stock, Real Estate, LLCs, Notes, etc.), please complete the asset description below and contact us regarding the
re-registration of your investment.
Asset Description (For Non-Cash Assets Only) Amount
SIGNATURE AND ACKNOWLEDGEMENT
I hereby agree to the terms and conditions set forth in this Rollover form and acknowledge having established a Self-Directed Account through execution of an
account application. I understand the rules and conditions applicable to a rollover. I qualify for the Indirect Rollover or Direct Rollover of assets listed in the
Asset Description above and authorize such transactions. If this is a Indirect Rollover or Direct Rollover, I have been advised to see a tax advisor due to the
important tax consequences of rolling assets into an self-direct account. If this is a Indirect Rollover or Direct Rollover, I assume full responsibility for this
Indirect Rollover or Direct Rollover transaction and will not hold the Plan Administrator, Custodian or Issuer of either the distributing or receiving plan liable for
any adverse consequences that may result. I understand that no one at Midland Trust or any of its licensees has authority to agree to anything different than
my foregoing understandings of Midland Trust policy. If this is a Indirect Rollover or Direct Rollover, I irrevocably designate this contribution of the assets
listed above as a rollover contribution. If this is an Indirect Rollover, I further certify the following by signing this form:
Your Signature: Date:
A. This rollover contribution is being made within 60 days after my receipt of funds from another IRA.
B. During the 12-month period prior to my receipt of the distribution being rolled over, I have not received a rollover distribution from any IRA
which was subsequently rolled over to another IRA.
C. I am not rolling over any Required Minimum Distributions with respect to the distributing plan.
FOR PROCESSING, RETURN TO: Midland ♦ P.O. Box 07520 ♦ Fort Myers, Florida 33919 ♦ 239.333.1032 ♦ 239.466.5496 Fax ♦ midlandtrust.com/secure-upload
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