Fillable TRANSFER AUTHORIZATION A. ACCOUNTHOLDER INFORMATION

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TRANSFER AUTHORIZATION A. ACCOUNTHOLDER INFORMATION

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The TRANSFER AUTHORIZATION A. ACCOUNTHOLDER INFORMATION form is 2 pages long and contains:

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  • 24 check-boxes
  • 19 other fields

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File type: PDF

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F27V4 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. IRA TO BE TRANSFERRED
Please select one: Tradiional IRA Roth IRA SEP IRA SIMPLE IRA Inherited Tradiional IRA Inherited Roth IRA
If you don’t know what type of IRA you currently hold, please contact your current IRA custodian.
Custodian name Account number (Please limit to one account per form)
Custodian address Contact person (if applicable)
City, State, ZIP Custodian phone number
C. CASH/ASSETS TO BE TRANSFERRED
Transfer all available cash
Liquidate all assets, then transfer all cash
Please note that this opion is only ofered by some IRA Custodians. Please check with your
current Custodian to verify whether they accept liquidaion instrucions from receiving insituions.
Transfer some cash in the amount of $
Please contact your current financial insituion to ensure that suficient cash is available.
If there isn’t, please ask them to liquidate your assets and turn them into cash.
Assets –
Madison cannot accept publicly traded securiies. Use this secion for transferring “alternaive assets.” Some asset transfers require addiional
documentaion, please contact transfers@madisontrust.com for addiional details.
Transfer the following assets:
Asset name Asset type Approximate asset value
Asset name Asset type Approximate asset value
Note: If you are transferring more than 4 assets, please attach a List of Assets Being Transferred form.
Full name Madison Trust Account Number
Client date of birth Client Social Security Number
This form is used only if you are transferring funds from an exising IRA. If you are rolling funds over
from a 401(k), 457, 403(b), or a similar plan, contact your current administrator to iniiate the rollover.
Please complete and submit this form via one of the following methods:
Mail: Fax: Secure Upload: www.madisontrust.com/uploads
If your current IRA Custodian requires an original ink signed Transfer Authorizaion form, we will noify you of their requirement within 2 business days of receiving your form.
TRANSFER AUTHORIZATION
Page 1 of 2
Madison account type:
Tradiional IRA Roth IRA SEP IRA
SIMPLE IRA Inherited Tradiional IRA
Inherited Roth IRA
D. FULL/PARTIAL TRANSFER **This field is required**
Please select one:
Parial Transfer Complete Transfer (Please note: This will close your account. Contact your current custodian for their closing requirements.)
F27V4 Copyright © 2019 Madison Trust Company Inc. All Rights Reserved.
madisontrust.com
Corporate Headquarters: 401 E. 8
th
St. Suite 200, Sioux Falls, SD 57103
E. TRANSFER INSTRUCTIONS
Please choose how you would like the custodian of your current IRA to transfer your cash/assets to Madison Trust.
Wire ($25) UPON RECEIPT A WIRE TAKES 1 BUSINESS DAY TO CLEAR
Insituion Name: Capital One Bank, N.A. Acct. Name: Madison Trust Company
Rouing Transit No.: 065000090 Acct. No.: 7527846263
For Further Credit: FBO [Accountholder’s name] [MTC Account #]
Please assign all asset transfers to Madison Trust Company, Custodian FBO [client’s name and Madison account number] and forward to
Madison Administraion Company, 1 Paragon Drive, Suite 275, Montvale, NJ 07645.
Check ONCE DEPOSITED, A BANK/INSTITUTION/CERTIFIED CHECK TAKES 5 BUSINESS DAYS TO CLEAR
Make checks payable to: Madison Trust Company Custodian FBO [client’s name and Madison account number] and forward to
Madison Administraion Company, 1 Paragon Drive, Suite 275, Montvale, NJ 07645.
F. MADISON TRUST PROCESSING TIMES AND FORM DELIVERY METHOD
G. ACCOUNTHOLDER AUTHORIZATION
Processing ime and delivery method is in regards to Madison Trust Company submiting the request to your current custodian. Turnaround ime and delivery
method back to MTC is strictly subject to your external custodian.
Processing Times:
Standard Processing: Transfer request will be sent in 4 business days. (default)
Expedited Processing: Transfer request will be sent next business day. ($50)
Transfer Form Delivery Methods:
Standard Delivery (default) Overnight Delivery ($50 fee applies)
**Please note: Any forms received ater 1PM EST will be considered received on the following business day (applies to both standard and expedited processing).**
Although MTC does not require a Medallion Signature Guarantee for transfers, your current custodian may have this requirement. Please verify with your cus
todian if they require a Medallion. NOTE: A medallion can be provided by most financial insituions with whom you have a relaionship and need not be from
the transferring insituion.
With my signature I acknowledge that the appointment of Madison Trust as Custodian will become efecive upon receipt of the assets from the prior custodian/trustee.
I further acknowledge that Madison Trust assumes no liability for the acion or inacion of the prior custodian/trustee as to the proper and imely transfer of funds.
Accountholder signature
Date (mm/dd/yy)
!
IMPORTANT! Please attach a copy of your most recent account statement from the financial insituion from which you are transferring.
TRANSFER AUTHORIZATION
Page 2 of 2
Medallion Signature Guarantee (if required)
For Madison Trust. Please do not fill in.
Letter of Acceptance
Please be advised that Madison Trust Company, as Custodian, is qualified to accept the requested transfer, and will hold the asset(s) in an IRA for the benefit of our
mutual client named above. The undersigned, an authorized signatory of Madison Administraion Company, LLC, hereby accepts the transfer of the above menioned
reirement asset(s) as agent for Madison Trust Company, Custodian.
Signature Date (mm/dd/yy)
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TRANSFER AUTHORIZATION A. ACCOUNTHOLDER INFORMATION

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Completed 15 April 2021

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