IRA Rollover Certification Form

IRA Account Information

Please enter your personal information and Solera National Bank IRA information.
Name*

First NameLast Name
Email*
example@example.com
Social Security Number*
Date of Birth*

MonthDayYear
IRA Account Number*
IRA Type*

Traditional IRARoth IRAInherited Traditional IRAInherited Roth IRA

IRA Rollover Type

Please enter the type of IRA Rollover you are completing.
Select one of the following IRA Rollover types:*

Late RolloverRollover from an IRADirect Rollover from Employer Sponsored Plan (401k, 403b, TSP, etc.)Indirect, 60-day Rollover from an Employer Sponsored Plan or IRARollover Conversion, pre-tax Employer Sponsored Plan or IRA to Solera National Bank Roth (post-tax) IRA.
Late IRA Rollover Self-Certifying Letter*

Please provide the self-certifying letter claiming eligibility for a waiver under IRS guidelines. For more information regarding the reporting of late rollovers, eligibility, requirements, and a self-certification letter template please refer to Internal Revenue Service Revenue Procedure 2016-47. Your tax advisor will assist you with completing this letter and reporting the late IRA Rollover exception to the IRS.
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We recommend you work with a tax advisor as this type of Rollover may be taxable.

In-Kind Asset Details
In-Kind Asset Name(s)*
In-Kind Asset Valuation*

Please provide a valuation of the asset(s). This value will be reported to the IRS on tax form 5498. We recommend working with a qualified asset appraiser.
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In-Kind Asset Proof of Ownership*

Please provide proof (statement, agreement, etc.) that the asset(s) ownership name is now the LLC/Trust you hold in your IRA at Solera National Bank.
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Acknowledgement & Signature
By signing below, I irrevocably elect to treat this contribution to the listed IRA as a Rollover for all legal and tax purposes. I certify that all the information on this form is true and correct to the best of my knowledge, and that Solera National Bank and my distributing custodian may rely on what I have provided. I accept all responsibilities regarding this Rollover, including eligibility requirements, initiation duties, and tax withholding. I have been advised to consult a competent advisor for legal and tax advice and have not been provided any such advise from Solera National Bank. I agree to indemnify and hold harmless Solera National Bank from any consequences related to this Rollover.
Clear
Date of Signature*

MonthDayYear
Should be Empty:

IRA Account Information