Direct Rollover or Transfer of A by liwenting

VIEWS: 26 PAGES: 3

									                                                                             Direct Rollover or Transfer of Assets
Instructions    For assistance, call 1-800-243-1574.
                Complete this form to authorize Virtus Mutual Funds and their agents to request a transfer of your IRA assets or Direct Rollover-
                Transfer from an Employer-sponsored Retirement Plan directly from another institution. Please provide us with a copy of a recent
                statement for your current account.
                Depositor should complete all sections of this form. Mail the completed form, along with a Virtus IRA Application & Adoption
                Agreement if you don’t already have a Virtus Mutual Funds IRA to:
                            Virtus Mutual Funds
                            c/o State Street Bank & Trust Company
                            P.O. Box 8301
                            Boston, MA 02266-8301.
                If you currently have a Virtus IRA, we recommend that you establish an additional Virtus IRA for a Direct Rollover-Transfer from an
                employer-sponsored retirement plan. No additional fees are incurred for establishing another Virtus IRA, and by doing so you may
                preserve important future tax benefits for yourself. Virtus Mutual Funds will assign an IRA account number and forward this form to
                the existing plan contact listed in Section B.
Section A       NAME AND ADDRESS OF DEPOSITOR

               _________________________________________________________________________________________________________
               Name                                                                             Date of Birth (required)

               _________________________________________________________________________________________________________
               Address (If your mailing address is a P.O. Box, you must provide your street address.)

               _________________________________________________________________________________________________________
               City                                                                                     State                                    Zip Code

               _________________________________________________________________________________________________________
               Social Security Number                                                                   Daytime Phone Number


Section B       EXISTING PLAN INFORMATION

               ____________________________________________________________________________________________________________________________________________
               Name of Existing Custodian/Plan                                                              Name of Individual or Dept. responsible for transfer/rollover

               _________________________________________________________________________________________________________
               Address of Existing Custodian/Plan                                                           Phone Number

               _________________________________________________________________________________________________________
               City                                                                                         State                                            Zip Code

               _________________________________________________________________________________________________________
               Applicant's/Participant's Name                                                               Applicant's/Participant's Account Number

Section C       TRANSACTION TYPE
Step 1                Establish New Virtus Mutual Funds IRA                                         Existing Virtus Mutual Funds IRA Account # __________
                      (Include a completed IRA Application & Adoption Agreement)
Step 2          This transaction should be reported/processed as:
                  Transfer          Direct Rollover         Conversion                             Transfer-in-Kind - If you have an existing Virtus Mutual
                                                                                                  Funds IRA with someone other than State Street Bank &
                                                                                                  Trust Company as custodian.
Step 3          Identification of Existing IRA/Plan and Receiving IRA
                This is a Transfer/Rollover/Conversion from:
                          Traditional IRA                      SEP IRA                              Inherited IRA
                          Roth IRA                             SIMPLE IRA                           Government 457 Plan*
                          Employer-Sponsored Qualified Retirement Plan*
                * Your employer may require other forms to process your request.

Step 4          Receiving IRA is a:
                        Traditional IRA**                               SEP IRA**                   Inherited IRA
                        Roth IRA***                                     SIMPLE IRA****

                ** You may not transfer from a Roth IRA to a Traditional IRA or a simplified employee pension (SEP) IRA or SIMPLE IRA (unless
                   this is a recharacterization transaction as permitted under IRS rules – consult the IRS or a tax professional for assistance, if
                   needed). Transfers or direct rollovers to a Traditional IRA or SEP IRA may be made from another Traditional IRA or SEP IRA,
                   qualified employer plan, 403(b) arrangement, eligible Section 457 plan or a SIMPLE IRA account (but not until at least 2 years
                   after the first contribution to your SIMPLE IRA account). Current Custodian/Trustee is responsible for determining 2-year
                   eligibility to transfer from a SIMPLE IRA to a Traditional IRA.
              *** Transfers to a Roth IRA are possible from another Roth IRA. Also, if the Roth IRA owner meets eligibility requirements,
                 transfers to a Roth IRA are possible from a Traditional IRA, from a SEP IRA, or from a SIMPLE IRA (but not until at least two
                 years after the first contribution to the SIMPLE IRA account), not from other types of tax-deferred accounts. A transfer to a Roth
                 IRA from another IRA will trigger federal income tax on the taxable amount transferred from the other IRA.

              **** Transfers to a SIMPLE IRA may be made only from another SIMPLE IRA. During the first two years after a SIMPLE IRA is
                 established, transfers from the SIMPLE IRA may be made only to another SIMPLE IRA; after 2 years, transfers may be made
                 from a SIMPLE IRA to a Traditional IRA or a Roth IRA. Current Custodian/Trustee is responsible for determining 2-year
                 eligibility to transfer from a Simple IRA to a Traditional IRA.

              Note: If you are establishing an inherited IRA (an IRA that will hold assets that you are receiving as the beneficiary of a deceased
              IRA owner or plan participant) please be sure to complete the necessary information in the IRA Application & Adoption Agreement.


Section D     TRANSFER/ROLLOVER/CONVERSION INSTRUCTIONS
            This section must be completed in full to avoid processing delays.

Step 1        I hereby direct you to transfer/rollover/convert my account in accordance with the following instructions:

                 Full                                                         OR       Partial
                        Liquidate all and forward proceeds to Virtus Mutual Funds.          Transfer/Rollover $____________________.
                        Transfer in-kind.                                                   Send all available cash.
                        Liquidate CD and transfer proceeds at maturity.                     Cash $______________________________.
                        Liquidate CD immediately.

Step 2           Asset Description                                                        Asset Description
                 ___________________________________________                              ________________________________________
                 ___________________________________________                              ________________________________________
                 ___________________________________________                              ________________________________________

Step 3        Tax Withholding Election (Complete only for transfer from another type of IRA to a Roth IRA)
              Under IRS rules, a transfer of a Traditional IRA, SEP IRA or SIMPLE IRA to a Roth IRA is treated for income tax purposes as a
              distribution of taxable amounts in the other IRA. IRS rules also require the custodian to withhold a minimum of 10% of the amount
              transferred for federal income taxes unless no withholding has been elected. See IRS Publication 505, “Tax Withholding and
              Estimated Tax” for more information.
              Caution: Withholding income taxes from the amount transferred (instead of paying applicable income taxes from another source)
              may adversely impact the expected financial benefits of transferring from another IRA to a Roth IRA (consult your financial adviser
              if you have a question). Because of this impact, you may elect not to have taxes withheld. However, you will remain liable for
              payment of applicable taxes and may be subject to tax penalties if your payments of estimated tax or tax withheld are insufficient
              under IRS guidelines. Please consult the IRS or your tax adviser for more information about this.

              Federal taxes will automatically be withheld at the rate of 10% unless you indicate a larger percentage or elect no withholding by
              checking one of the boxes below. State tax withholding may also apply if federal income tax is withheld, depending upon the rules
              of your state.

                        Do not withhold taxes; or
                        Withhold taxes at the rate of ___________% (must be greater than 10%)



Section E     INVESTMENT CHOICES TO VIRTUS MUTUAL FUNDS

                Invest the transfer/rollover/conversion in accordance with the investment instruction provided in the IRA Application & Adoption
                Agreement for my State Street Bank and Trust Company Individual Retirement Custodial Account.

                 Invest the transfer/rollover/conversion as follows:

                 Asset Description                             Percentage                Asset Description                           Percentage
                 __________________________________%_________                             __________________________________%_________
                 __________________________________%_________                             __________________________________%_________
                 __________________________________%_________                             __________________________________%_________

                                                                   Percentages must total 100%
              I acknowledge that I have sole responsibility for my investment choices and that I have received a current prospectus for each
              Fund I select. Please read the prospectus(es) of the Fund(s) you select before investing.
              I understand that the requirements for a valid transfer to a Traditional IRA, SEP IRA, Roth IRA or SIMPLE IRA are complex, and I
              acknowledge that I have the responsibility for complying with all requirements and for the tax results of any such transfer.
Section F    AUTHORIZATION TO TRANSFER/ROLLOVER

            To Custodian:
            I, the undersigned Depositor, certify to the current IRA custodian or trustee that I have established a successor Individual
            Retirement Custodial Account meeting the requirements of Internal Revenue Code Section 408(a), 408(k), 408(p) or 408A (as the
            case may be) to which assets will be transferred, and I certify to State Street Bank and Trust Company that the account from which
            assets are being transferred meets the requirements of Internal Revenue Code (and that the transfer satisfies the requirement for a
            nontaxable transaction).

            This will serve as authorization to transfer/rollover the assets indicated in section A, as outlined in section C and transfer/rollover to
            an IRA that I have established through Virtus Mutual Funds, with State Street Bank and Trust Company as Custodian.

            I understand that if I make any non-deductible contributions to the funds rolled over from a qualified plan, or otherwise commingle
            rollover amounts with non-deductible accumulation amounts, I will have relinquished the right to ultimately roll over the funds
            distributed to me to another qualified plan. If I do establish a rollover IRA and make future non-deductible contributions to this
            account, I hereby release and hold harmless State Street Bank and Trust Company, Virtus Mutual Funds and their respective
            employees, officers, trustees/directors, agents and affiliates from liability for any loss, damage, or injury which I may sustain as a
            result of my election not to establish two separate Individual Retirement Custodial Accounts. Furthermore, if I am making a rollover
            contribution, I understand that such rollover contribution is irrevocable.


            ____________________________________________________________________________________________________________________________________________
            Depositor's Signature                                                                Date

            Please note: If you have reached age 70 ½, and are subject to a required minimum distribution, please contact Virtus Mutual Funds
            to establish a distribution plan if you have not already met your required minimum distribution for the current tax year.

            IMPORTANT: Your existing custodian may require a signature guarantee. A signature guarantee helps to protect you and
            the parties who act upon your instructions from fraud. It guarantees that the person who signs this is, in fact, the person
            named. If a signature guarantee is required, notarization will not be acceptable. Please check with your existing custodian
            for requirements.

                                                                                                   Place Signature Guarantee Stamp
             _______________________________________________________________________________                     Here
             Name of Bank or Firm



             _______________________________________________________________________________
             Signature Guarantee By:



             _______________________________________________________________________________
             Signature and Title of Officer




            Custodian
            State Street Bank and Trust Company agrees to accept transfer of the above amount for deposit to the Depositor’s State Street
            Bank and Trust Company Individual Retirement Custodial Account, and requests the liquidation and transfer of assets as indicated
            above.




7107                                                                                                                                              04-09

								
To top