PO Box 2789
Omaha, NE 68103-2789
Fax: 866-468-6268
TDA 081 DS 06/20Page 1 of 2
Account Number: U.S. Social Security Number:
Account Owner’s Full Legal Name:
Primary Phone Number: Email Address:
Please make check payable to TD Ameritrade Clearing, Inc. We accept checks payable in U.S. dollars and through a U.S. bank, as well as
checks drawn o Canadian banks.
Acceptable Foreign Instruments (checks drawn o Canadian banks). TD Ameritrade receives a referral fee from a third-party service
provider on eligible currency exchange transactions. To facilitate the currency exchange process, banks receive revenue based on
an assessed currency markup rate.
Form can be mailed to PO Box 2789, Omaha, NE 68103-2789. For overnight delivery, send to 200 S 108th Ave, Omaha, NE 68154, or fax to
• Please include your account number and the tax year of the contribution on the memo section of your check.
• Because contributions must be made in cash, all stock deposits must be 60-day rollovers, direct rollovers, transfers, or Roth conversions.
• Please note: If no tax year indication is made, your contribution will be reported as a current-year contribution.
Cash Amount:
Tax Year: Date of Deposit:
Type of Contribution
Traditional Contribution
Roth Contribution
SEP Employer Contribution
SIMPLE Contribution
Please note that SEP and SIMPLE contributions are always designated as current year contributions.
Cash Amount: Symbol/Asset: Number of Shares:
Direct Rollover* – Irrevocable Qualifying Direct Rollover from my employer’s 401(k), 403(b), profit-sharing plan, money purchase plan, etc.,
or Roth portion of my employer’s retirement plan, received into a Traditional, Rollover, SEP, or Roth IRA.
60-Day Rollover – Irrevocable Qualifying Rollover processed less than 60 days ago. Account Owner attests to the following: that the funds
deposited as an Irrevocable Qualifying Rollover do not contain any amounts from a Required Minimum Distribution; that these funds are
being deposited within the allowable 60-day time period; and that Account Owner is allowed only one rollover per 12-month period. Account
Owner further agrees to be bound by the election of this deposit as an Irrevocable Qualifying Rollover.
Direct Transfer* – Transferred from another firm where it was held with the identical account type and/or title.
COVID-19 Repayment – Clients have up to 3 years to repay a Coronavirus Related Distribution (CRD) from the day the funds were
distributed, if qualified.
Roth Conversion – As a result of a distribution from a Traditional IRA, Rollover IRA, SEP IRA, or SIMPLE IRA.**
* Please be advised that a transfer and a rollover are not the same thing. A rollover is the result of a distribution from another qualified plan or IRA. A transfer is the result
of a direct transfer from one institution to another. If there is a doubt, contact the sending financial institution to determine if the funds were processed as the result of a
distribution or a transfer.
**Please note that SIMPLE IRA assets cannot be converted until two years after the initial date of funding.
The contribution limit information is based on federal law as stated in the Internal Revenue Code, and is believed to be accurate. However, eligibility
to contribute is dependent on your tax filing status and personal situation. Please consult a competent tax advisor concerning your specific
contribution eligibility, and any applicable state laws which may dier from federal law.
I instruct TD Ameritrade Clearing, Inc. to deposit the funds or securities into my IRA (the “Account”) according to the instructions on this IRA
Deposit Slip. I understand that the deposit of funds or securities into the Account may have important and possibly irrevocable tax consequences.
I acknowledge that TD Ameritrade, as a discount brokerage firm, does not provide investment or tax advice; that the Account is self-directed; and
that I assume full responsibility for this transaction. I release and agree to indemnify and hold harmless TD Ameritrade, Inc. and TD Ameritrade
Clearing, Inc., their divisions, ocers, employees, directors, representatives, owners, aliates, successors, and assigns from liability for any adverse
consequences that may result from this transaction.
By Depositing a foreign instrument, you:
Agree to indemnify and hold TD Ameritrade and the third party service provider, harmless from any and all losses, costs, claims, or
financial obligations that may arise from any act or omission with respect to your account and from any and all losses, costs, claims, or
financial obligations that may arise from acting upon the instructions provided herein.
Certify that (i) you have the authority to enter into the transactions set forth above; and (ii) you understand that transactions are governed
by an account agreement executed by the account owner with TD Ameritrade (the “Agreement”).
Individual Retirement Account (IRA)
Deposit Slip
Reset Form
You understand and agree that the third party service provider, will convert the funds into U.S. Dollars using the conversion rate and
transmit the proceeds to the designated recipient. You also acknowledge and agree that TD Ameritrade cannot guarantee when the
service provider will post the funds for credit, and this process may take several days, during which the funds will be held by the service
provider in its bank account commingled with other assets of that provider, and while there: (i) are not protected by SIPC or
TD Ameritrade’s excess SIPC coverage, (ii) will not bear interest and (iii) will not be eligible for other earnings credits.
By my signature below, I certify that the information and instructions provided, and the elections made by and through this IRA Deposit Slip, are true
and correct. TD Ameritrade Clearing, Inc. may justifiably rely upon the instructions and elections made herein and is authorized to deposit the funds
or securities in the manner provided by this IRA Deposit Slip.
Account Owner’s Signature:
Original signature required; electronic signatures and/or signature fonts are not authorized.
Investment Products: Not FDIC Insured * No Bank Guarantee * May Lose Value
TD Ameritrade, Inc. and TD Ameritrade Clearing, Inc., members FINRA/SIPC. TD Ameritrade is a trademark jointly owned by
TD Ameritrade IP Company, Inc. and The Toronto-Dominion Bank. © 2020 TD Ameritrade.
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