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A disclaimer is generally any statement intended to specify or delimit the scope of rights and obligations that may be exercised and enforced by parties in a legally recognized relationship.

Agree

Rollover/Direct Rollover Form

1. Account Information

Your Name:

Your SSN:

Street Address:

City:

State:

Zip:

Phone Number:

American IRA Account Number:

Email:

2. Current Custodian/Trustee Information

Name of Custodian/Trustee:

Account Number:

Street Address:

City:

State:

Zip:

Phone Number:

Is this an Inherited Account?

Type of account:

3. Rollover Details

The total amount I am rolling over is: $

Rollover

I am an eligible person to perform this transaction:

4. Rollover Instructions to Resigning Custodian

To roll over CASH, please follow the instruction below. Contact our office for wire instructions.
To roll over INVESTMENTS (Private Stock, Real Estate, LLCs, Notes, etc.), please complete the asset description below and contact us regarding the re-registration of your investment. Cash and Assets are to be made payable/assigned to: New Vision Trust Company CFBO (Account Name) (Account Type)

Asset Description:

Amount:

Signature and Acknowledgement

By my signature below, I confirm that I have read and consent to the terms of this document and I further acknowledge that I have read and consent to the terms of the New Account Application, Custodial Agreement (Form 5305, 5305-A, 5305-RA, 5305-SA, 5305-SEP, 5305-C or 5305-EA, as application, “collectively referred to as “5305” or 401K Plan Agreement (“Sponsored Plan”) as applicable, Fee Schedule, Account Disclosure Statement and any other documents that govern my Custodial Account or Sponsored Plan, as such documents are currently written, or as they may be amended from time to time, (the “Documents”), which are incorporated by reference herein. (In the event of a conflict between the Documents and the 5305 and/or Sponsored Plan applicable to my Custodial Account, the 5305 or Sponsored Plan shall govern).
I hereby agree to the terms and conditions set forth in this rollover form and acknowledge having established a Self-Directed Account through execution of the (Type of Account) Account Application. I understand the rules and conditions applicable to a Rollover or Direct Rollover. I qualify for the  Rollover or  Direct Rollover of assets listed in the Asset Liquidation above and authorizes such transactions. If this is a Rollover or Direct Rollover, I have been advised to see a tax advisor due to the important tax consequences of rolling assets into a self-direct account. If this is a Rollover or Direct Rollover, I assume full responsibility for this Rollover or Direct Rollover transaction and will not hold the Plan Administrator, Custodian, as disclosed in the Custodial Agreement, or Issuer of either the distributing or receiving plan liable for any adverse consequences that may result. I understand that no one at Custodian and/or Administrator has authority to agree to anything different than my foregoing understandings of Custodian and/or Administrator policy. If this is a Rollover or Direct Rollover, I irrevocably designate this contribution of assets with a value of $_________ as a rollover contribution. By signing this form, I certify that I am completing this rollover within:

Rollover or Direct Rollover?

Value?

A. 60 calendar days following the day I received the assets, I have not performed a rollover from an IRA within the last 12 months and the rollover DOES NOT contain my Required Minimum Distribution

B. If I am a non-spouse beneficiary, this is a direct roll over from an employer plan and the rollover contribution DOES NOT contain my Required Minimum Distribution.

I Accept the Acknowledgement

Print Name:

Your Signature:

Date:

Corporate Headquarters: New Vision Trust Company, 401 E. 8th Street, Suite 200R, Sioux Falls, South Dakota 57103

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