Internal 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

401k Plan Account Information
401k Plan Name*
401k Account Number*
401k Plan Type*

Traditional 401k PlanRoth 401k PlanInherited Traditional 401k PlanInherited Roth 401k Plan
Please * my 401k plan account once the internal IRA Rollover is complete.

Internal IRA Rollover Details
By continuing, I am requesting Solera National Bank internally rollover the following assets (cash and/or in-kind) from my 401k plan account to my IRA. Both accounts are held at Solera National Bank.
Exact IRA Rollover Amount*
Will you be rolling over in-kind (non-cash) assets?*

NoYes

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.
Cancelof
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.
Cancelof

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 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 relay 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 advice 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