Express IRA Application

Tell Us Who You Are:

Mr.
Mrs.
Ms.

Name

First Name: Last Name:

Address

Street Address: City State ZIP Code

Is This Your Mailing Address?

Yes
No

Date of Birth (mm/dd/yyyy):

Contact 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:

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Email

This field is for validation purposes and should be left unchanged.