Instructions for Completing the Citibank IRA

Transfer and Direct Rollover Form

TRANSFERS:
To transfer an IRA that you have at another financial institution to a Citibank IRA, please follow these steps:
• To help identify your account, please include a copy of your most recent account statement (less than 90 days old) from your
current institution.
• Complete Sections 1 and 3 of the Citibank IRA Transfer and Direct Rollover Form.
(Note: Non-spouse IRA beneficiaries must first have inherited funds moved to a beneficiary IRA in their name at the current
institution, prior to requesting the transfer.)
• If you do not select an IRA investment option in Section 3, funds will be placed in an IRA Insured Money Market Account (IMMA).
Please note that the selected term of an IRA CD account will begin on the business day that Citibank receives the funds and the
then-current interest rate for that term will be applied to the account balance; and for IRA IMMA and Existing Day to Day Savings
the then-current variable interest rate will begin to be applied to the account balance on the business day that Citibank receives
the funds.
• Carefully read Section 4 before signing. If you do not have an existing Citibank IRA, Roth IRA, Rollover IRA, or SEP-IRA, you must
also complete a Citibank IRA Application.
• Return the completed form(s) to any Citibank branch or mail the form(s) to:
Retirement Plan Services
Attn: Transfer Department
PO Box 769001

DIRECT ROLLOVERS:
When you leave an employer and want to arrange a direct rollover of qualified plan assets to a Citibank IRA, please follow
these steps:
• To help identify your account, please include a copy of your most recent account statement (less than 90 days old) from your
current institution.
• Contact your employer to let them know the amount of your plan assets you want rolled over to a Citibank IRA.
• Verify whether or not your employer requires that their own distribution form and/or an “acceptance letter” be used to request
the rollover.
• Complete Sections 2 and 3 of the Citibank IRA Transfer and Direct Rollover Form. If you do not select an IRA investment option
in Section 3, funds will be placed in an IRA Insured Money Market Account (IMMA). Please note that the selected term of an IRA
CD account will begin on the business day that Citibank receives the funds and the then-current interest rate for that term will be
applied to the account balance; and for IRA IMMA and Existing Day to Day Savings the then-current variable interest rate will begin
to be applied to the account balance on the business day that Citibank receives the funds.
• Carefully read Section 4 before signing. If you do not have an existing Citibank IRA, Roth IRA, Rollover IRA, or SEP-IRA, you
must also complete a Citibank IRA Application.
• Return the completed form(s) to any Citibank branch or mail the form(s) to:
Retirement Plan Services
Attn: Transfer Department
PO Box 769001
San Antonio, TX 78245-9951
• Citibank will contact your employer directly to arrange for your direct rollover. Your employer will be instructed to send a check
payable to Citibank, N.A., as Successor Custodian for your IRA, for the requested amount of your direct rollover.
If you have any questions, please call Retirement Plan Services at 1-800-695-5911*.
For text telephone/TTY anywhere in the US: 1-800-788-6775.

*To ensure quality service, calls are recorded.

© 2016 Citigroup Inc. Citi with Arc Design is a registered service mark of Citigroup Inc.
Item CIS070SB (Rev. 01/15) 1471970  09/16
The Citibank IRA Transfer and Direct Rollover Form
PLEASE ATTACH A COPY OF YOUR MOST RECENT ACCOUNT STATEMENT (LESS THAN 90 DAYS OLD) FROM YOUR CURRENT
INSTITUTION. If you do not have an existing Citibank IRA, Roth IRA, Rollover IRA, or SEP-IRA, you must also complete a Citibank IRA Application.
1. To Transfer Assets from Another Institution
Please note: Transfers of securities will not be accepted. Securities intended for transfer must be liquidated prior to transfer.
Account Number at Current Trustee Plan Owner Name Social Security Number

Name of Current Trustee

Street Address, City, State, and Zip of Current Trustee

Transfer From/To (please check one):
□ IRA to IRA
□ Roth IRA to Roth IRA
□ SEP-IRA to SEP-IRA
□ Roth Conversion IRA to Roth Conversion IRA
□ Rollover IRA to Rollover IRA
□ Inherited IRA to Inherited IRA
□ Inherited Roth IRA to Inherited Roth IRA
What would you like to transfer?
□ 100% of the plan
□ Less than 100% of the plan (specify dollar amount): $_________________________________________________
From account number:___________________________________________________  □ Immediately  □ At Maturity
From account number:___________________________________________________  □ Immediately  □ At Maturity
(There may be interest penalties if you terminate a CD before maturity.)

2. To Direct Rollover Assets from an Employer’s Qualified Plan

Please note: Direct rollovers of securities will not be accepted. Securities intended for direct rollover must be liquidated prior to rollover.
Name of Employer Plan Owner Name Social Security Number

Employer Street Address, City, State, and Zip Employer Phone

Direct Rollover From/To (please check one):

□ 401(k) Plan to IRA □ 403(b) Plan to IRA □ 457 Plan to IRA □ Money Purchase Keogh Plan to IRA
□ 401(k) Plan to inherited IRA □ 403(b) Plan to inherited IRA □ 457 Plan to inherited IRA □ Money Purchase Keogh Plan to inherited IRA
□ 401(k) Plan to SEP-IRA □ 403(b) Plan to SEP-IRA □ 457 Plan to SEP-IRA □ Profit Sharing Keogh Plan to IRA
□ 401(k) Plan to Roth IRA □ 403(b) Plan to Roth IRA □ 457 Plan to Roth IRA □ Profit Sharing Keogh Plan to inherited IRA
□ Roth 401(k) Plan to Roth IRA □ Roth 403(b) Plan to Roth IRA □ Roth 457 Plan to Roth IRA □ Money Purchase Keogh Plan to Roth IRA
□ Roth 401(k) Plan to inherited Roth IRA □ Roth 403(b) Plan to inherited Roth IRA
□ Roth 457 Plan to inherited Roth IRA □ Profit Sharing Keogh Plan to Roth IRA
How much would you like us to collect from your retirement plan? Date of Direct Rollover:
□ 100% of the amount that is eligible for a direct rollover. □ Collect the Direct Rollover immediately.
□ Less than 100%. (specify dollar amount): $___________________________________________ □ Collect the Direct Rollover on (date):_________________________
3. Select An Investment Option Into Which Funds Will Be Transferred/Rolled Over
If no investment is selected, funds will be placed in an applicable IRA, Roth IRA, or SEP-IRA Insured Money Market Account (IMMA). You will receive
the interest rate in effect when Citibank receives your funds.
□ CD □ Term □ Amount □ Insured Money Market Account □ Existing Day to Day Savings Account
________________________ $______________________________ $____________________________________ $____________________________________________
(Minimum investment $250) (No minimum investment) (No minimum investment)
Account Number _____________________
4. Acceptance
By signing this form you acknowledge that:
• You authorize Citibank to contact the financial institution or employer named above on your behalf, to request remittance of the IRA or retirement
plan assets described above to Citibank, N.A. as successor custodian;
• You accept the applicable premature withdrawal penalty for accounts terminated prior to the maturity date;
• You cannot revoke any election to have a contribution treated as a rollover;
• You certify that only eligible rollover distributions are to be direct rollovers.
Owner Signature___________________________________________________________________________________________________________ Date_____________________________________
You will receive confirmation of this request.
Citibank RPS Use Only — Directions And Information For Financial Institution Named Above
Citibank, N.A. accepts its appointment as successor custodian for the transfer described above.
Citibank, N.A. Authorized Signature/Stamp:______________________________________________________________________________ Date_____________________________________
All requests must include one of the following: Medallion Signature Guarantee, Signature Verification or Notary Stamp
Please make checks payable to Citibank, N.A. as successor custodian and deliver to:
Retirement Plan Services, attn: Transfer Department; PO Box 769001, San Antonio, TX 78245-9951
© 2016 Citigroup Inc. Citi with Arc Design is a registered service mark of Citigroup Inc. Item CIS070SB (Rev. 01/15) 1487164  10/16

OFFICE COPY
The Citibank IRA Transfer and Direct Rollover Form
PLEASE ATTACH A COPY OF YOUR MOST RECENT ACCOUNT STATEMENT (LESS THAN 90 DAYS OLD) FROM YOUR CURRENT
INSTITUTION. If you do not have an existing Citibank IRA, Roth IRA, Rollover IRA, or SEP-IRA, you must also complete a Citibank IRA Application.
1. To Transfer Assets from Another Institution
Please note: Transfers of securities will not be accepted. Securities intended for transfer must be liquidated prior to transfer.
Account Number at Current Trustee Plan Owner Name Social Security Number

Name of Current Trustee

Street Address, City, State, and Zip of Current Trustee

Transfer From/To (please check one):
□ IRA to IRA
□ Roth IRA to Roth IRA
□ SEP-IRA to SEP-IRA
□ Roth Conversion IRA to Roth Conversion IRA
□ Rollover IRA to Rollover IRA
□ Inherited IRA to Inherited IRA
□ Inherited Roth IRA to Inherited Roth IRA
What would you like to transfer?
□ 100% of the plan
□ Less than 100% of the plan (specify dollar amount): $_________________________________________________
From account number:___________________________________________________  □ Immediately  □ At Maturity
From account number:___________________________________________________  □ Immediately  □ At Maturity
(There may be interest penalties if you terminate a CD before maturity.)

2. To Direct Rollover Assets from an Employer’s Qualified Plan

Please note: Direct rollovers of securities will not be accepted. Securities intended for direct rollover must be liquidated prior to rollover.
Name of Employer Plan Owner Name Social Security Number

Employer Street Address, City, State, and Zip Employer Phone

Direct Rollover From/To (please check one):

□ 401(k) Plan to IRA □ 403(b) Plan to IRA □ 457 Plan to IRA □ Money Purchase Keogh Plan to IRA
□ 401(k) Plan to inherited IRA □ 403(b) Plan to inherited IRA □ 457 Plan to inherited IRA □ Money Purchase Keogh Plan to inherited IRA
□ 401(k) Plan to SEP-IRA □ 403(b) Plan to SEP-IRA □ 457 Plan to SEP-IRA □ Profit Sharing Keogh Plan to IRA
□ 401(k) Plan to Roth IRA □ 403(b) Plan to Roth IRA □ 457 Plan to Roth IRA □ Profit Sharing Keogh Plan to inherited IRA
□ Roth 401(k) Plan to Roth IRA □ Roth 403(b) Plan to Roth IRA □ Roth 457 Plan to Roth IRA □ Money Purchase Keogh Plan to Roth IRA
□ Roth 401(k) Plan to inherited Roth IRA □ Roth 403(b) Plan to inherited Roth IRA
□ Roth 457 Plan to inherited Roth IRA □ Profit Sharing Keogh Plan to Roth IRA
How much would you like us to collect from your retirement plan? Date of Direct Rollover:
□ 100% of the amount that is eligible for a direct rollover. □ Collect the Direct Rollover immediately.
□ Less than 100%. (specify dollar amount): $___________________________________________ □ Collect the Direct Rollover on (date):_________________________
3. Select An Investment Option Into Which Funds Will Be Transferred/Rolled Over
If no investment is selected, funds will be placed in an applicable IRA, Roth IRA, or SEP-IRA Insured Money Market Account (IMMA). You will receive
the interest rate in effect when Citibank receives your funds.
□ CD □ Term □ Amount □ Insured Money Market Account □ Existing Day to Day Savings Account
________________________ $______________________________ $____________________________________ $____________________________________________
(Minimum investment $250) (No minimum investment) (No minimum investment)
Account Number _____________________
4. Acceptance
By signing this form you acknowledge that:
• You authorize Citibank to contact the financial institution or employer named above on your behalf, to request remittance of the IRA or retirement
plan assets described above to Citibank, N.A. as successor custodian;
• You accept the applicable premature withdrawal penalty for accounts terminated prior to the maturity date;
• You cannot revoke any election to have a contribution treated as a rollover;
• You certify that only eligible rollover distributions are to be direct rollovers.
Owner Signature___________________________________________________________________________________________________________ Date_____________________________________
You will receive confirmation of this request.
Citibank RPS Use Only — Directions And Information For Financial Institution Named Above
Citibank, N.A. accepts its appointment as successor custodian for the transfer described above.
Citibank, N.A. Authorized Signature/Stamp:______________________________________________________________________________ Date_____________________________________
All requests must include one of the following: Medallion Signature Guarantee, Signature Verification or Notary Stamp
Please make checks payable to Citibank, N.A. as successor custodian and deliver to:
Retirement Plan Services, attn: Transfer Department; PO Box 769001, San Antonio, TX 78245-9951
© 2016 Citigroup Inc. Citi with Arc Design is a registered service mark of Citigroup Inc. Item CIS070SB (Rev. 01/15) 1487164  10/16

CLIENT COPY
The Citibank IRA Transfer and Direct Rollover Form
PLEASE ATTACH A COPY OF YOUR MOST RECENT ACCOUNT STATEMENT (LESS THAN 90 DAYS OLD) FROM YOUR CURRENT
INSTITUTION. If you do not have an existing Citibank IRA, Roth IRA, Rollover IRA, or SEP-IRA, you must also complete a Citibank IRA Application.
1. To Transfer Assets from Another Institution
Please note: Transfers of securities will not be accepted. Securities intended for transfer must be liquidated prior to transfer.
Account Number at Current Trustee Plan Owner Name Social Security Number

Name of Current Trustee

Street Address, City, State, and Zip of Current Trustee

Transfer From/To (please check one):
□ IRA to IRA
□ Roth IRA to Roth IRA
□ SEP-IRA to SEP-IRA
□ Roth Conversion IRA to Roth Conversion IRA
□ Rollover IRA to Rollover IRA
□ Inherited IRA to Inherited IRA
□ Inherited Roth IRA to Inherited Roth IRA
What would you like to transfer?
□ 100% of the plan
□ Less than 100% of the plan (specify dollar amount): $_________________________________________________
From account number:___________________________________________________  □ Immediately  □ At Maturity
From account number:___________________________________________________  □ Immediately  □ At Maturity
(There may be interest penalties if you terminate a CD before maturity.)

2. To Direct Rollover Assets from an Employer’s Qualified Plan

Please note: Direct rollovers of securities will not be accepted. Securities intended for direct rollover must be liquidated prior to rollover.
Name of Employer Plan Owner Name Social Security Number

Employer Street Address, City, State, and Zip Employer Phone

Direct Rollover From/To (please check one):

□ 401(k) Plan to IRA □ 403(b) Plan to IRA □ 457 Plan to IRA □ Money Purchase Keogh Plan to IRA
□ 401(k) Plan to inherited IRA □ 403(b) Plan to inherited IRA □ 457 Plan to inherited IRA □ Money Purchase Keogh Plan to inherited IRA
□ 401(k) Plan to SEP-IRA □ 403(b) Plan to SEP-IRA □ 457 Plan to SEP-IRA □ Profit Sharing Keogh Plan to IRA
□ 401(k) Plan to Roth IRA □ 403(b) Plan to Roth IRA □ 457 Plan to Roth IRA □ Profit Sharing Keogh Plan to inherited IRA
□ Roth 401(k) Plan to Roth IRA □ Roth 403(b) Plan to Roth IRA □ Roth 457 Plan to Roth IRA □ Money Purchase Keogh Plan to Roth IRA
□ Roth 401(k) Plan to inherited Roth IRA □ Roth 403(b) Plan to inherited Roth IRA
□ Roth 457 Plan to inherited Roth IRA □ Profit Sharing Keogh Plan to Roth IRA
How much would you like us to collect from your retirement plan? Date of Direct Rollover:
□ 100% of the amount that is eligible for a direct rollover. □ Collect the Direct Rollover immediately.
□ Less than 100%. (specify dollar amount): $___________________________________________ □ Collect the Direct Rollover on (date):_________________________
3. Select An Investment Option Into Which Funds Will Be Transferred/Rolled Over
If no investment is selected, funds will be placed in an applicable IRA, Roth IRA, or SEP-IRA Insured Money Market Account (IMMA). You will receive
the interest rate in effect when Citibank receives your funds.
□ CD □ Term □ Amount □ Insured Money Market Account □ Existing Day to Day Savings Account
________________________ $______________________________ $____________________________________ $____________________________________________
(Minimum investment $250) (No minimum investment) (No minimum investment)
Account Number _____________________
4. Acceptance
By signing this form you acknowledge that:
• You authorize Citibank to contact the financial institution or employer named above on your behalf, to request remittance of the IRA or retirement
plan assets described above to Citibank, N.A. as successor custodian;
• You accept the applicable premature withdrawal penalty for accounts terminated prior to the maturity date;
• You cannot revoke any election to have a contribution treated as a rollover;
• You certify that only eligible rollover distributions are to be direct rollovers.
Owner Signature___________________________________________________________________________________________________________ Date_____________________________________
You will receive confirmation of this request.
Citibank RPS Use Only — Directions And Information For Financial Institution Named Above
Citibank, N.A. accepts its appointment as successor custodian for the transfer described above.
Citibank, N.A. Authorized Signature/Stamp:______________________________________________________________________________ Date_____________________________________
All requests must include one of the following: Medallion Signature Guarantee, Signature Verification or Notary Stamp
Please make checks payable to Citibank, N.A. as successor custodian and deliver to:
Retirement Plan Services, attn: Transfer Department; PO Box 769001, San Antonio, TX 78245-9951
© 2016 Citigroup Inc. Citi with Arc Design is a registered service mark of Citigroup Inc. Item CIS070SB (Rev. 01/15) 1487164  10/16

FINANCIAL ADVISOR COPY