Express IRA Application Tell Us Who You Are: Mr. Mrs. Ms. Name First Name: Last Name: Address Street Address: City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is This Your Mailing Address? Yes No Date of Birth (mm/dd/yyyy):...123456789101112...12345678910111213141516171819202122232425262728293031...202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Contact Number:Email Address: Type of IRA: Traditional Roth SEP Other Funding Will Come From A (Optional): Transfer from an existing IRA Rollover from another IRA Rollover from a previous employer’s qualified plan(401K, 403(b), etc) Rollover/Transfer Information (Optional):Account Number with Present Custodian or Plan Administrator: Type of Account: Traditional IRA SEP IRA Roth IRA SIMPLE IRA 401(k), 403(b), 457(b) or other Qualified Retirement Plan (Note: You may initiate a Direct Rollover from a 401(k) or other eligible Qualified Retirement Plan using this form. However, your Plan Administrator will require you to complete its plan distribution forms packet before processing.)Owner's Name as it Appears on the Account: Name of Custodian or Plan Administrator: City: CAPTCHAEmailThis field is for validation purposes and should be left unchanged.