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Copyright © 2019 Madison Trust Company Inc. All Rights Reserved.
madisontrust.com
Corporate Headquarters: 401 E. 8
th
St. Suite 200, Sioux Falls, SD 57103
A. ACCOUNTHOLDER INFORMATION
B. INVESTMENT INSTRUCTIONS
Name of IRA Trus:
C. DOCUMENT REQUIREMENTS
D. DELIVERY INSTRUCTIONS
E. ACKNOWLEDGEMENT, AUTHORIZATION, & SIGNATURE
Several documents may be required to complete this transacion, please see the appropriate Madison Trust lowchart based on the asset you wish to transfer.
Send the documents via regular mail (default) Send the documents via overnight mail ($50 fee applies)
Name Address
City State ZIP
I hereby acknowledge that I am solely responsible for the investment instrucions I am making. I agree to indemnify, hold harmless, and release Madison Trust and
Madison Administraion Company from any and all liabiliies that either or both may incur directly or indirectly from my investment. I further acknowledge that I am
solely responsible for the success or failure of this investment. I hereby authorize the transfer requested above for my Madison Trust IRA idenified in Secion A above.
Accountholder signature Date
Full name Account number
Use this form to transfer assets from your IRA into your IRA Trus .
Please complete and submit this form via one of the following methods:
Mail: Fax: Secure Upload: www.madisontrust.com/uploads
IRA TO IRA TRUST TRANSFER
Asset name Number of shares/units
Asset name Number of shares/units
Asset name Number of shares/units
Asset name Number of shares/units
Assets to invest into
the Trus:
(Invest all shares/units
unless otherwise noted)
click to sign
signature
click to edit