Rollover Form

Advisor Name*

First Last

Client Name*

First Last

Phone Number

Transfer from/to*

Describe briefly

Rollover or Transfer?*

401(k)/403(b)/401(a)to a Rollover IRA

Rollover IRA to Roth IRA (conversion)

Rollover IRA to Rollover IRA transfer

Roth IRA to Roth IRA transfer

Change in account type

Other

Reason the rollover or transfer is being considered:*

Change of employment

Retirement

Termination of retirement plan

Company closure/layoff

In-service distribution

Other

Other reason for a rollover or transfer:

Does the Client have an established relationship with A & I?*

Yes

Are the retirement assets currently managed by A & I?*

Yes

Alternatives to the rollover/transfer include*

For example, leaving the account assets in the employer’s plan.

Is the source account a 401k/403b/401a?*

Yes

This question refers to the account where it is coming from.

What benefits or services might be lost if the client left the current 401(k)/403b/401a plan?*

More creditor protection (IRAs are held to state creditor laws regarding malpractice, divorce or other lawsuits; their maximum caps can be lower than ERISA protections).

The ability to take loans from the plan (or there are existing loans).

The ability to take penalty-free withdrawals before age 59 1/2 (if the client is planning to retire between ages 55 and 59 1/2).

Ability to do back-door Roth contributions.

The ability to defer mandatory distributions if still working past age 72.

If the employee owns appreciated employer securities, potential loss of favorable tax treatment of net unrealized appreciation if the assets are all rolled into an IRA. (Advisors can mitigate this by taking out the NUA assets as a lump sum distribution.)

The potential to opt for guaranteed annuity-like payments from the plan at retirement (if available).

Death benefit (if available).

Check all that apply

What benefits or services would be gained by having the assets managed in a rollover IRA?*

Check all that apply.

Current fees*

List the fees and costs paid in the account where it is coming from.

Proposed fees and compensation*

List fees associated with the destination account (R/O IRA or Roth IRA account). AUM fee, other fees and expenses.

Received from client*

404(a)(5) disclosure document

Account Statement

Client unable to provide disclosure document

Any other compensation?*

Yes

Is our company, any individual advisor including yourself, or any affiliate of our company receiving any direct or indirect compensation in addition to the advisory fee charged by the company for the rollover?

If yes, then identify the fees/compensation:*

Client needs and considerations:*

Does not wish to leave assets with former employer or employer is terminating the plan

Dissatisfied with the limited investment options

Dissatisfied with the performance of the investment alternatives

Would like to consolidate assets

Wants more direct control over the assets

Prefers to have professional advice/management

Would like to have more holistic planning services for other matters

Would like a lifetime-income option

Check all that apply.

Recommendations: Investment Options*

Generally, a broader range of investment solutions are available in the new IRA, in comparison to those available in the existing plan.

In my view, the overall quality of the investment solutions available in the new IRA are higher compared with those available to the existing plan.

Other

Investment reasons why an IRA would be beneficial to the client.

Other investment reason for the recommendation

Recommendations: Service*

Personalized services from our company

Consultations to assess investment objectives and risk profile

Ongoing consulting and recommended changes to investment strategy, model or third-party advisers as necessary

Individualized advice for client’s IRA(s)

Discretionary investment management

Customized performance reporting for client’s IRA(s)

Financial planning

Consolidation of assets for overall portfolio management

Other

Service reasons that an IRA would be beneficial to the client.

Other service reason for the recommendation

Client will be able to make penalty-free withdrawals from the new account?*

Yes

Client has confirmed that he or she has already attained age 59-½ and, therefore, may be immediately eligible to take penalty-free withdrawals from an IRA.

Explain*

If the Client is younger than 59-½, an ERISA Plan may have a tax advantage over an IRA. The Client may be eligible to take penalty-free withdrawals from an ERISA Plan as early as age 55 (as opposed to age 59-½ in the case of an IRA).

Client has confirmed that there is no reasonably foreseeable need for him or her to seek protection from creditors and lawsuit judgments?*

Yes

Client has confirmed that he or she does not beneficially own any employer stock through his or her existing account?*

Yes

Explain*

If the existing plan is a defined contribution plan and the client beneficially owns employer stock through such plan then this may be important. Certain tax benefits are available to participants who take in-kind distributions of employer stock, which are lost if such amounts are rolled over to an IRA.

Reasonable compensation?*

Yes

The advisory fee being charged in connection with the rollover or transfer is consistent with industry norms and is reasonable for the services proposed.

To the best of my knowledge, the client will benefit from rolling over their plan assets or IRA into the proposed IRA.*

Yes

IRA Rollover Recommendation Form