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IRA-Conversion by qingyunliuliu


									IRA Conversion
State Farm Mutual Funds® Individual Retirement Accounts

This form is used to convert a Traditional IRA, SEP IRA, or SIMPLE IRA with State Farm Life, State Farm Variable, or State Farm Mutual Funds to a
State Farm Mutual Funds Roth IRA.

Do Not use this form for assets held outside of State Farm or with State Farm Bank. To convert assets held outside of State Farm or with State Farm
Bank, first transfer the assets to a Traditional IRA, SEP IRA, or SIMPLE IRA with State Farm Mutual Funds. Once the assets are received, you may
use this form to convert the assets.

If you have any questions please call 1-800-447-4930.


 Check with the present custodian/trustee to see if there are any fees for liquidating/transferring and converting the assets. Complete all sections.
 Be sure to include the account number of the Traditional IRA in Section 3 and have a State Farm Mutual Funds Roth IRA open to receive the

• If you are over 70 ½, your Required Minimum Distribution is NOT eligible to be converted to the Roth IRA.

• You cannot convert and reconvert an amount until the later of the year following the year of the conversion or 30 days after the conversion is

• You are responsible for maintaining records of your Roth IRA conversions, recharacterizations, and annual contributions in order to properly
  complete your federal tax forms.

• Read the State Farm Mutual Funds Roth IRA Custodial Account Agreement and Disclosure Statement, which contain relevant information for
  converting to a State Farm Mutual Funds Roth IRA.

•   Mail or fax forms to:               State Farm Mutual Funds
                                        P.O. Box 219548
                                        Kansas City, MO 64121-9548

FIRST NAME                                                             MI            LAST NAME


CITY                                                                                 STATE                     ZIP CODE

TELEPHONE (include area code)                                                        SOCIAL SECURITY NUMBER

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3 PRESENT CUSTODIAN, ADMINISTRATOR OR TRUSTEE                                                                              Company that currently has the account


 CITY                                                                                      STATE                          ZIP CODE

 TELEPHONE (include area code)                                                             ACCOUNT NUMBER

4 CONVERSION REDEMPTION INSTRUCTIONS (FROM ACCOUNT)                                                                        Select one option from each item below.

Conversion Amount: (Select one)                                                                       Liquidate and Convert: (Select one)
If you don't specify an amount, the current custodian may liquidate all assets

            All (Approximate Value $                                                  )                      Immediately
             $                                                of my present account                         At Maturity
                                                                                                                                      Month - Day - Year
Account Type:               Traditional IRA                        SEP IRA                         SIMPLE IRA
(Select one)                                                                                       Date you began participation
                                                                                                                                            Month - Day - Year
                                                                                                   Note: A SIMPLE IRA cannot be converted to a Roth IRA
                                                                                                   prior to the expiration of the two year period beginning on
                                                                                                   the date participation began in a SIMPLE IRA plan.

                   Fund                       Share Class        Conversion                             Fund                         Share Class      Conversion
                                              (If applicable) (Must meet fund                                                     (If applicable) (Must meet fund
                                               (check one)       minimum)                                                          (check one)       minimum)

                                                   A         B                   %                                                      A         B                 %
                                                   A         B                   %                                                      A         B                 %

                                                   A         B                   %                                                      A         B                 %
                                                   A         B                   %                                                      A         B                 %
                                                   A         B                   %                                                      A         B              %
                                                                                                                                                      Total = 100 %
Place proceeds in:              New State Farm Roth IRA                    Existing State Farm Roth IRA (account #)
                                (Application attached)

6 AUTOMATIC INVESTMENT PLAN                                                          Complete only if you are converting an existing State Farm Mutual Funds IRA

If converting the full fund/account, the automatic investment, if any, will be discontinued in the State Farm Mutual Funds IRA you are converting from.
To continue your current automatic investment or to change the amount and/or fund, please call 1-800-447-4930.

        Move my current automatic investment to my Roth IRA (amount and fund to remain unchanged).

 If converting a partial fund/account, the automatic investment, if any, will continue into the State Farm Mutual Funds IRA you are converting from.

        Stop the current automatic investment in my State Farm Mutual Funds IRA.

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 The taxable portion of your proceeds may be subject to federal income tax withholding, at a rate of at least 10%, and state income tax withholding, if
 applicable to your state of residence, unless you elect for federal and state withholding not to apply. If you elect not to have withholding apply or
 do not have enough tax withheld, you may be responsible for payment of estimated taxes, and there may be tax penalties if your withholding and
 estimated payments are not sufficient. You may change this withholding election by checking the appropriate box(es) below. The tax withholding
 election you make will only apply to this conversion request.
 If you are under age 59 ½, any amounts withheld and not contributed to your State Farm Mutual Funds Roth IRA within 60 days may be
 subject to a 10% early distribution penalty.
 Federal Income Tax Withholding – If you do NOT check one box, you direct the present custodian listed in Section 3 to withhold 10% of the
 conversion distribution.
 Choose One
               Do not withhold federal income tax. (Skip to Section 8, State Farm Bank®* will not withhold state income tax for any state if federal
               income tax is not withheld.)
                Withhold federal income tax at a rate of             % (not less than 10%)
 State Income Tax Withholding - If you have questions regarding state withholding, contact your tax advisor or your state's taxing authority. If
 federal tax is withheld, State Farm Bank will withhold at least the minimum amount required by your state unless you specify a higher amount below.
 (Note: State Farm Bank will only withhold if you live in a state that requires us to withhold.)

  Choose One: (Complete only if you elected to have federal income tax withheld.)

          Do not withhold state income tax. I understand this election will not apply in states that do not permit persons to elect out of withholding.

          Withhold my state's minimum requirement.

          Withhold this amount $                                       . (We will withhold at least your state's minimum requirement)
  * State Farm Investment Management Corp. ("SFIMC") withholds taxes on behalf of State Farm Bank

I authorize and request the Custodian/Trustee/Administrator or its agents of my IRA specified in Section 3 to liquidate the requested distribution from
my IRA and convert the funds to my State Farm Mutual Funds Roth IRA. I certify that the above conversion qualifies as a valid conversion per the
Internal Revenue Code section 408A and the applicable regulations.

Participant's Signature                                                                                   Date

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