Full - Transfer All Available Cash
Partial - Send Only $
(Please include minimum balance requirement plus suggested 3 years fees)
page 1 of 1
Transfer Form
For processing, return to: Midland Trust | PO Box 07520, Fort Myers, FL 33919 | Fax: 239.466.5496 | Phone: 239.333.1032
www.midlandtrust.com/secure-upload
Updated 09/02/2020
Use this form to transfer funds directly from your existing IRA to your Midland Trust Company IRA.
Please include a copy of a recent statement from your current custodian.
PERSONAL INFORMATION
1
Name (Your name as it appears in your plan)
Mr. Ms. Mrs. Dr.
Social Security Number
Legal Address City, State, Zip
Phone Midland IRA Account Number
CURRENT CUSTODIAN/TRUSTEE
2
Name of Custodian/Trustee Account Number
Transfer Department Address City, State, Zip
Phone Number Contact Name (optional)
Type of Account
Traditional Roth SEP SIMPLE BENEFICIARY HSA ESA
3
TRANSFER DETAILS (Market fluctuations and/or administrative fees may impact the transfer amount received)
SIGNATURE AND ACKNOWLEDGEMENT
4
1. I hereby agree to the terms and conditions set forth in this Account Asset Transfer Authorization and acknowledge having
established a self directed account through execution of the account application.
2. I understand the rules and conditions applicable to an Account Transfer.
3. I qualify for the account transfer of assets listed in the Asset Liquidation above and authorize such transactions.
Your Signature:
Date:
ACCEPTANCE OF RECEIVING CUSTODIAN
Midland Trust Company accepts appointment as successor custodian/trustee for the assets identified on this form. Midland Trust ASSUMES NO FIDUCIARY
OBLIGATIONS TO YOU AS IT HAS NO INVESTMENT CONTROL OVER THE FUNDS AND ACTS ONLY AS A CUSTODIAN OF THE ACCOUNT.
By: Date: Account #:
Type of Account
SEPRothTraditional SIMPLE HSA ESA
Beneficiary IRA Beneficiary Roth IRA
Option One: Cash Transfer
(Funds must be liquidated prior to request)
Option Two: In-Kind Transfer
(For Non-Cash Transfers Only)
Full - Transfer All Cash and Assets In-Kind
Partial - Send Only the Assets Listed Below
(Please include minimum balance requirement plus suggested 3 years fees)
Centennial Bank
ABA: 082902757
Credit Name: Midland Trust Company
Credit Account: 1030311
Further Credit: Client Name, Midland Acct #
All Funds Wired To
If your custodian does not accept electronic copies, how would you like this sent?
Mail (No Charge - Default)
Overnight ($30 Fee)
Asset Description (not required for c
ash transfer)
