IRA Rollover Request Form - Capital One

1 Request FOR A TRANSFEROR DIRECT ROLLOVERThis form is being used to complete a:Traditional IRA transfer to a Capital One 360 Traditional IRA Roth IRA transfer to a Capital One 360 Roth IRA Simple IRA transfer to a Capital One 360 Traditional IRAE mployer Plan [401(k), 403(b) or other]direct Rollover to a Capital One 360 Traditional IRA Employer Plan[401(k), 403(b) or other]direct Rollover to a Capital One 360 Roth IRA Note:P lease consult a tax professional to your eligibility for a direct Rollover ofyour Employer Name and NAMELAST NAMEADDRESSADDRESSCITYSTATEZIPS ocial Security NumberDate of BirthDaytime PhoneCapital One 360 IRA Savings Account NumberWho is presently holding your account?TRUSTEE, CUSTODIAN OR INSURANCE CARRIERACCOUNT OR POLICY NUMBERPLAN NAME (if applicable)PHONE NUMBERTRUSTEE/CUSTODIAN ADDRESSCITYSTATEZIPI nstructions to Current Trustee/CustodianPlease liquidate the plan balance, in the amount shown below, and make a check payable to: Capital One 360 fbo_____.

2 (Customer Name)Mail the check to the address listed on the reverse side of this form. Pl ease include the Customer s Account Number _____ on the check, or include a copy of this form.( Capital One 360 IRA Account Number)Amount to be rolled over or transferredNote:Ca pital One 360 does not accept rollovers in and directly Rollover /transfer $_____ of my accountLiquidate and directly Rollover /transfer all of my accountProcess the Rollover /transfer:ImmediatelyOn the maturity date of _____Page 1 of 2 Request FOR A TRANSFEROR DIRECT ROLLOVERC ustomer SignatureNote:If you are age 70 1 2or older, and are required to take a minimum distribution, you may not transfer or Rollover the amount of yourrequired minimum distribution to Capital One requesting this transfer or direct Rollover from the plan indicated above, I m certifying that all of the information provided is correct and that the funds being transferred or rolled over are eligible to be deposited intothe Capital One 360 IRA I ve indicated.

3 I m acknowledging that all funds being transferred or rolled over are subject to all applicable Federal and State laws and regulations, theIndividual Retirement Account Custodial Agreement, and the IRA Savings Account Terms and Conditions. I accept responsibility for this transaction, and I will hold neither the Plan Administrator of the distributing plan nor Capital One 360 (including any of its affiliates) liable for any adverse consequences arising from my _____(IRA Holder)(Date)_____ _____(Signature Guarantee [if required by current institution] )(Date)What s NextPlease mail this form to Capital One 360 at the address listed below. Capital One 360 will use this form to Request your funds. Your current institution may require a signature guarantee on this form, or may have additional requirements before releasing your funds.

4 To avoid delays, please contact them before submitting this Request to Capital One deposit will be put in the IRA Savings Account you have specified on the reverse side of this form. If you want to use thisdeposit for an IRA CD, please visit after we have received the funds. We will post the deposit as soonas we receive it. If you have questions about the status of your Rollover or transfer, please contact the transferring One 360 AcceptanceThe person named above has an IRA with Capital One 360, and Capital One 360 agrees to a ccept the t ransf er or direc t r ollover of _____( Capital One 360 Authorized Representative) (Date)Mail to: Capital One Box 60St. Cloud, MN 56302 Phone: 877-955-8700 Overnight Mail Address: Capital One 36030 7th Avenue SouthSt.

5 Cloud, MN 56301 Page 2 of 2