Transcription of CONTRIBUTION AND INVESTMENT SELECTION
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CONTRIBUTION AND INVESTMENT SELECTION
Page 1 of 26107 / 2414R (Rev. 3/2018) 2018 Ascensus, LLCCONTRIBUTION AND INVESTMENT SELECTIONPART 1. ROTH IRA OWNERName (First/MI/Last) _____Social Security Number _____Date of Birth _____ Phone _____Email Address _____Account Number_____ Suffix _____PART 2. ROTH IRA TRUSTEE OR CUSTODIANTo be completed by the Roth IRA trustee or custodianName _____Address Line 1 _____Address Line 2 _____City/State/ZIP _____Phone _____ Organization Number _____PART 3. CONTRIBUTION INFORMATIONC ontribution Amount _____ CONTRIBUTION Date _____ CONTRIBUTION TYPE (Select one) 1. Regular (Includes catch-up contributions ) CONTRIBUTION for Tax Year _____ 2. Rollover (Distribution from a Roth IRA or eligible employer-sponsored retirement plan that is being deposited into this Roth IRA) By selecting this transaction, I irrevocably designate this CONTRIBUTION as a rollover.
Investment Description or Amount (new or existing) Number or Maturity Date Rate DEPOSIT METHOD Cash or Check (If the contribution type is transfer, the check must be from a financial organization made payable to the trustee for this Roth IRA.)
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