Outgoing IRA Transfer Letter of Intent

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 IRASEP IRAInherited Traditional IRAInherited Roth IRA
IRA Owned Trust/LLC Name*

Outgoing IRA Transfer Details
By continuing, you are requesting to move the following assets (cash and/or in-kind) from the IRA-owned entity checking account to the IRA to complete your transfer request. Be advised, all outgoing IRA transfer requests are subject to a $25 outgoing transfer fee.
Exact IRA Transfer Cash Amount*
Will you be distributing in-kind (non-cash) asset?*

NoYes
Please * once the transfer is complete.

In-Kind Asset Details

Please ensure these assets are listed on the receiving IRA custodian's transfer request.
In-Kind Asset Name(s)*
In-Kind Asset Valuation*

In additional to this form, please provide a valuation of the asset(s). We recommend working with a qualified asset appraiser.
Cancelof

Payment Instructions
Solera National Bank will follow the check or wire delviery instructions provided on the receiving IRA custodian's transfer request.

Be advised, funds sent by check are issued as cashier's check. Solera National Bank is not responsible for any loss/delay due to mailing.

Be advised, funds sent via wire will incur an additional $30 outgoing wire fee.
How would you like your funds sent to the receiving IRA custodian?*

Cashier's CheckDomestic Wire
Shipping Options*

Regular Mail2-day Mail (based on current rates)

Acknowledgement & Signature
I certify that I am the IRA account owner, the beneficiary, or individual legally authorized to complete this form and the proper part to receive payment(s) and/or assets from the IRA. I certify that all information provided on this form is true and accurate. I understand that processing this request may result in applicable fees and account termination.

By signing below, I certify that the valuation provided separately to Solera National Bank for any inkind assets is true and correct to the best of my knowledge and that Solera may rely on their valuation for reporting purposes. I accept all responsibilities regarding this valuation. I certify that Solera National Bank has not provided me with tax, investment, or legal advice; and I will indemnify Solera National Bank, its affiliates, successors, and assignors, from all liability arising from this request. I agree that all decisions regarding this are my own and assume responsibility for any consequences that may arise. My signature serves as legal authorization granting Solera National Bank authority to process this request.
Clear
Date of Signature*

MonthDayYear
Should be Empty:

IRA Account Information