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PO Box 2760
Omaha, NE 68103-2760
Fax: 866-468-6268
TDA 995 07/20
Questions? Call an IRA representative at 888-723-8504; Option 2.
Full Legal Name:
Date of Birth:
U.S. Social Security Number:
Address of Record:
City: State: ZIP Code:
Primary Phone: Email Address:
Should TD Ameritrade need to contact you in regards to this request, your preferred method of contact is: M Email M Primary Phone
Convert my IRA number _____________________________________ to my Roth IRA number _____________________________________
M I have satisfied my Required Minimum Distribution
If you will reach RMD age or older by December 31 of the current year, a Required Minimum Distribution (RMD) must be satisfied prior to
requesting a Roth conversion. RMD age is 70 1/2 if born on or before June 30, 1949. RMD age is 72 if born after June 30, 1949. A valid Roth
IRA is required to be established prior to completing a Roth conversion.
I wish to convert my entire account to my Roth IRA.
Partial conversion of the following assets:
Cash in the amount of $_______________________
Quantity of Shares Name of Asset
_____________________________________ __________________________________________________________________________
_____________________________________ __________________________________________________________________________
_____________________________________ __________________________________________________________________________
The decision to convert all or a portion of an IRA is irrevocable after the conversion has been completed.
4. TAX WITHHOLDING ELECTION (Please indicate by checking a box for Federal and State.)
A. Federal Withholding
Please note: If no withholding is indicated, we will not withhold federal taxes.
Please withhold taxes from my distribution at a rate of: _____________% or $____________________. Withholding amount cannot be
less than 10% of total distribution. (Please note: Any amounts withheld for taxes and not replaced into an IRA account within 60 days will be
considered a distribution and may be subject to a 10% early withdrawal penalty if you are under age 59½.)
B. State Withholding
Please note: If no withholding is indicated, we will not withhold state taxes.
Please withhold taxes from my distribution at a rate of:_____________% or $_____________________.
I declare my permanent state of residence is (state):________________________________________, and that my election should reflect the
requirements of that state.
Please note: TD Ameritrade Clearing, Inc. advises you to contact your tax professional before making any election regarding state withholding
elections. State law is subject to change, and TD Ameritrade Clearing, Inc. is not responsible for changes in state law that occur after the
publication date of this form.
I understand that, subject to the provisions of the Agreement, I have full discretion and control over the form of payment or payments of the entire balance in
the Account. I shall exercise control by directing that such payment or payments be made as described above, and the Custodian shall have no responsibility or
liability with respect to the choice of any such form of payment or payments. I attest that I am the proper party to receive payment(s) from this IRA and that all
information provided by me on this form, including supplemental material, is true and accurate. I certify that no tax advice has been given to me by TD Ameritrade
Clearing, Inc. and that all decisions regarding this withdrawal are my own. I expressly assume responsibility for any adverse consequences which may result
from the withdrawal; and I indemnify and hold harmless TD Ameritrade, Inc. and TD Ameritrade Clearing, Inc. and their divisions, ocers, employees, directors,
representatives, owners, aliates, successors, and assigns. Please note if no date is indicated below, the withholding election will default to receipt date of the
form. By my signature below, unless otherwise indicated above, I expressly waive withholding for federal and state income taxes.
Account Owner’s Signature:
Original signature required; electronic signatures and/or signature fonts are not authorized.
Roth Conversion Form
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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