Instructions for an incoming rollover
591306 (Rev 06 – 02/18) Page 1 of 2
Possible Plan Types eligible to roll over
- 401(k) plan - 457 Governmental plan
- Profit sharing plan - Simple IRA
- Money purchase plan - SEP IRA
- Pension plan - Traditional IRA
- 403(b) plan - ESOP
Funds ineligible to roll over
Your plan cannot accept rollovers of the following:
- Hardship distributions
- Required minimum distributions
- Roth IRAs
- Inherited IRAs
- Indirect Roth rollovers (except you may be able to do an
indirect rollover of the taxable portion of a distribution
from a designated Roth account)
- Non-deductible IRA contributions
Employer Sponsored Plan rollovers
You can rollover an account from an employer sponsored plan
such as a 401(k), profit sharing, or pension plan. Complete
the Rollover form and indicate the company and the full plan
name including the Plan Type.
Required: Include a distribution statement that provides
detail of the type of contributions that make up the
distribution amount, such as pre-tax, after-tax or Roth.
You may be asked to provide additional plan documentation
to validate the distributing plan’s qualification.
IRA rollovers
If IRAs are eligible for rollover into your plan, you are
certifying on the Rollover form that the proceeds from the
IRA originated either from a qualified employer-sponsored
plan or from contributions distributed from a traditional
IRA from which you took a tax deduction on your federal
income tax return.
Required: Include a copy of your IRA statement.
Indirect rollovers
An indirect rollover must be completed within 60 days of your
receipt of the distribution. After 60 days, the funds cannot be
rolled over to another qualified plan unless accompanied by a
Certification for Late Rollover Contribution Form.*
For a loan offset from an employer sponsored plan that was due
to (1) plan termination or (2) failure to meet the repayment
terms because of your severance from employment, the 60-day
rollover period is extended through the due date (including
extensions) for filing your individual tax return for the tax year
in which the loan offset is treated as distributed from the
employer sponsored plan.
To complete an indirect rollover you must send a cashier’s
check or money order along with your distribution
statement. The distribution statement provides detail of the
distribution date and type of contributions.
*For more information on the qualifications for a waiver of the 60
day Requirement, check the website for Retirement Plans
FAQs relating to self-certification Waivers of the 60-Day Rollover
Requirement. If you qualify for one of the self-certification waivers
of the 60 day requirement, you may request a Certification for Late
Rollover Form by calling the Retirement Service Center at 1-800-
Rollover instructions
Request the rollover check.
Contact your former retirement plan administrator or IRA
administrator to request that your rollover check be issued to:
Wells Fargo Bank, N.A.
For benefit of: [YOUR NAME]
Trustee for: [QUALIFIED PLAN NAME of plan receiving the rollover]
Complete the form on page 2 of this document.
You must certify that the check you are submitting represents funds
that are eligible to be rolled over into your plan and that the rollover
is in accordance with applicable IRS and plan rules.
Send the form, check and required
Mail the completed rollover form, rollover check (unless wiring
funds) and the required documentation to the following address:
By external mail:
Wells Fargo Institutional Retirement and Trust
DSR- D1118-026
1525 West WT Harris Blvd.
Charlotte, NC 28262-8522
By wire:
ABA Routing Transit Number: Wells Fargo Bank, N.A.
Beneficiary Account Number: 0000840245
(Must be 10 digits in length)
Beneficiary Account Name: Trust Wire Clearing
(NOTE: Must be on line 2)
Receiving Plan Code:
Receiving Plan Name:
Participant Name and last 4 digits of SSN
AU = 0046327
(Note: The AU # is critical in expediting the wire.)
Address, if needed for wiring funds:
Wells Fargo Bank, N.A.
550 South Fourth Street
Minneapolis, MN 55415
*The above address is for use only when wiring funds.
Checks sent to this address WILL result in a processing delay.
Avoid delays
To avoid delays in investing your rollover check in your plan account,
please review and comply with these instructions. If the required
information is missing, your check will be held and not invested. You
will be notified if documentation is missing. If you do not provide the
necessary information, your rollover check will be returned to
If you have any questions regarding the form or instructions, call the
Retirement Service Center at 1-800-728-3123, Monday through
Friday, 7:00 a.m. to 11:00 p.m. Eastern Time.
Incoming Rollover
591306 (Rev 06 – 02/18) Page 2 of 2
Participant information
Name (last, first, middle initial) Social Security number
Address Birth date
Address Hire date
Address Phone Number
Retirement Plan Receiving Funds
Existing account
Select the origin of your rollover:
Employer Sponsored plan
Required Documentation: Distribution Statement - for rollovers from Employer-sponsored plans
Retirement plan name (include Plan Type) (Possible Plan Types Eligible – 401(k), 403(b), 457, profit sharing, money purchase, pension, ESOP)
Pre-tax contributions
IRA (Simple, SEP, Traditional)
Required Documentation: IRA Statement
Pre-tax contributions
Investment direction
If you are enrolled in the plan, your rollover proceeds will be invested according to your current investment elections.
If you are not enrolled in the plan or have not made investment elections, your rollover proceeds will be invested according to your
plans default investment.
Employee signature
By signing this form, I certify that
(1) I have read and understand the form and agree to the terms and conditions,
(2) the information on this form is true and correct,
(3) this rollover is permitted and is in accordance with all applicable IRS and plan rules, including applicable timing requirements in the
event this is an indirect rollover*,
(4) I understand that decisions regarding rollovers have important tax consequences, and I have been advised to seek the guidance of
a tax professional with regard to this decision, and
(5) I assume full and sole responsibility for the consequences of this decision. If my rollover is from an IRA, I understand that I can
only roll over amounts from an IRA that have never been taxed previously. By submitting this form, I am certifying that my rollover
into the Plan represents a distribution from an IRA that originated from a qualified employer-sponsored plan or from contributions
distributed from a “traditional IRA” from which I took a tax deduction on my federal income tax return and that no other contributions
have been made to the IRA.
*If you qualify for one of the self-certification waivers of the 60 day requirement, you may request a Certification for Late Rollover
Form by calling the Retirement Service Center at 1-800-728-3123.
Signature Date
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