brokerage ira account roth ira conversion form · pdf filebrokerage ira account roth ira...

Brokerage IRA Account Roth IRA Conversion Form XXXXXXX 029300

Use the enclosed postpaid envelope to return this form or mail directly to:

T. Rowe Price BrokerageA Division of T. Rowe Price Investment Services, Inc.P.O. Box 17435Baltimore, MD 21297-1435

For overnight mail only:T. Rowe Price BrokerageA Division of T. Rowe Price Investment Services, Inc.4515 Painters Mill Road, OM–17300Owings Mills, MD 21117-4903

1 Your Current T. Rowe Price Brokerage Traditional IRA Account Registration

Please note: You will need a separate Roth IRA Conversion Form for each type of Brokerage IRA account you are converting.

Traditional IRA

Rollover IRA

SEP-IRA

Owner’s Name (exactly as it appears on existing account) Date of Birth (MM/DD/YYYY)

Account Number Social Security Number

2 Investor Information

Street Address or P.O. Box

City State ZIP

Daytime Phone Evening Phone

E-mail Fax Number

If you already have a Brokerage Roth IRA at T. Rowe Price, please list the account number here:

We will invest the conversion amount into this account for you.

• UsethisformtoconvertanexistingT.RowePriceBrokerageTraditional IRA (including a Rollover IRA or SEP-IRA) account to an existing or new Roth IRA.

• IfyouwanttoconvertTraditionalIRAassetsthatareheldatanotherfinancial institution, you must first establish a Traditional IRA with T. Rowe Price Brokerage, transfer the assets, and then convert them to a Roth IRA. (Please request a Brokerage Transfer Form and a Brokerage IRA New Account Form to do this.)

• AllaccountoptionsontheTraditionalIRAaccountyouare converting, including dividend reinvestment and telephone/ computer services, will be carried over automatically to the new Roth IRA (with the exception of systematic contributions and beneficiary designations).

• IfyouareconvertingyourentireT.RowePriceBrokerageTraditionalIRA, your money market sweep account will be converted as well. If you are executing a partial conversion, only those specified non-money market securities will be converted. A zero-balance Roth IRA sweep account will be established in the same money market fund as held in your Traditional IRA sweep account. (NOTE: You may not make a partial conversion of your Traditional IRA money market sweep account.)

• Forhelpwiththisformortorequestmoreinformation,call 1-800-638-5660.

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3 Conversion Instructions

Please note: If you select a dollar amount, the actual amount of the conversion may be slightly higher or lower due to market fluctuation.

Reminder: You may not make par-tial conversions of your Traditional IRA money market sweep account.

Full Conversion

Please convert my entire Traditional IRA to a Roth IRA. All positions are to be converted in kind.

Partial Conversion

Please convert in kind the following security positions in my Traditional IRA to a Roth IRA:

Quantity Asset Description and Symbol (by dollar amount, number of shares, or percentage)

All positions converted will be converted in kind.

If you need additional space, please attach a separate signed sheet, or you can make a copy of this page.

4 Name Your Beneficiaries

Please note that the beneficiary information on your Brokerage Traditional IRA will not carry over to your new Roth IRA. If you do not have an existing Roth IRA at T. Rowe Price, please complete this section. These beneficiary designations will replace any beneficiary designations you currently have on file for your T. Rowe Price Roth IRA.

Below, indicate the percent of your account to be distributed to the primary beneficiary(ies) upon your death. The total must equal 100%.

• If you do not indicate a percentage, it will result in equal allocation among the appropriate beneficiaries.

• Ifaprimarybeneficiarydiesbeforeyou,wewillrecalculatethepercentagesproportionatelyamong the surviving primary beneficiaries unless you instruct otherwise.

• Weapplythesamemethodtosecondarybeneficiaries.Note: A secondary beneficiary receives distributions only if no primary beneficiaries survive you.

I have attached instructions to name a complex beneficiary (e.g., a trust) or more beneficiaries.

I do not wish to name any beneficiaries at this time (this option does not apply if you have an existing Roth IRA). If a beneficiary is not designated on my IRA, inheritance may default to a surviving spouse or to the rules governing an estate in my state of residence.

I already have a Roth IRA at T. Rowe Price and wish to keep the existing beneficiaries.

Primary Beneficiary(ies) Name Relationship

1.

Social Security Number Birth Date (MM/DD/YYYY) % of Distribution

%

Name Relationship

2.


%

Name Relationship

3.


%

Total =%

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4 Name Your Beneficiaries (Continued)

Secondary Beneficiary(ies) Name Relationship

1.


%

Name Relationship

2.


%

Name Relationship

3.


%

Total =%

Choose one tax withholding election. If you do not check a box, we will be unable to process your Roth IRA conversion.

Do not withhold federal income tax from my conversion amount. I understand that I may be responsible for payment of estimated tax and may incur penalties under the estimated tax rules if my withholding and estimated tax payments are insufficient.

I want federal income tax withheld and understand that the withholding will be done at a rate of 10% unless a different withholding percentage is specified here: ____%. I also understand that the amount withheld may be subject to an additional 10% early withdrawal penalty.

Important state tax withholding information:T. Rowe Price will withhold state tax if, at the time of your payment, the address listed on your account at T. Rowe Price is within a mandatory withholding state and you have federal income tax withheld. State taxes will be withheld from your distribution in accordance with the respective state’s rules.

You may change this withholding election by written request prior to the conversion.

5 Choose Your Tax Withholding

6 Continue Your Systematic Contributions

If you are converting an existing T. Rowe Price Brokerage Traditional IRA, the services on that Traditional IRA will be carried over automatically to the new Roth IRA, with the exception of systematic contributions. If you would like your systematic contributions to continue, check one box below: Yes, continue investing my systematic contributions (same amount and day of the month) in my

Traditional IRA.

or Yes, continue my systematic contributions (same amount and day of the month) but invest in my Roth IRA.

Did you remember to:

3 Provide your existing Traditional IRA account number in Section 1?

3 Provide your Social Security number in Section 1?

3 Check the proper tax withhold-ing box in Section 5?

3 Provide your signature in the Owner’s Signature box?

By signing this form, I certify that:

n I authorize T. Rowe Price Brokerage to convert my Traditional IRA to a Roth IRA as directed by me in Section 3.

n I acknowledge that I am bound by the terms of the Account Agreement outlined in the Brokerage/Brokerage IRA Account or Brokerage Advantage Account Handbook previously received, which are incorporated by reference herein. If I do not understand any provision therein, I will notify T. Rowe Price Brokerage. I have the authority and legal capacity to establish a self-directed IRA and to purchase mutual fund shares and other securities. If I am opening a money fund sweep account, I have received, read, and agree to the terms of the fund’s prospectus. I am of legal age in my state.

n I acknowledge that I am responsible for determining the nature, potential value, and suitability for me of any particular security, transaction, or investment strategy and that T. Rowe Price does not give legal or tax advice regarding particular investments, including advice involving suitability of, and investment strategies for, particular investments.

n I received, read, and agreed to the T. Rowe Price Traditional and Roth IRA Disclosure Statement and Custodial Agreement at least seven days prior to the date that I signed this form.

7 Signature

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DB/05550-06.wbi K123-081 3/0982021

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PLEASE SIGN HERE ➔

n I understand that the services on the Traditional IRA I am converting (including the dividend reinvestment and tele-phone/computer services and systematic contributions if authorized in Section 6) will also be duplicated on this Roth IRA. With respect to those services, I authorize T. Rowe Price, the T. Rowe Price funds, and their affiliates and agents to act on any instructions believed to be genuine, including telephone/computer services. The T. Rowe Price funds use reasonable procedures to verify the identity of the shareholder and the person(s) granted trading privileges, if applica-ble, when servicing an account by telephone. I understand that it is T. Rowe Price’s policy to accept transaction instruc-tions from and provide account information to the registered account owner(s) only, unless the account owner(s) has provided written authorization to T. Rowe Price to grant trading privileges to another person. I further understand that it is my responsibility to monitor the activity in my account and not to provide account information, including my online user name and password, to anyone. The funds and their agents are not liable for any losses that may occur from acting on unauthorized instructions. Any redemption checks will be sent only to the owner(s) shown in Section 1 and to the address in Section 2. All services are subject to conditions set forth in each fund’s prospectus.

n Unless I check the box below, I am required by the Securities and Exchange Commission to provide my name, address, and securities position at the request of the companies whose securities I own.

Do not release my name, address, and securities position to the securities issuer.

n PREDISPUTE ARBITRATION CLAUSE. I agree to settle by arbitration any controversy between myself and T. Rowe Price; its parent or affiliates; and/or any such officers, directors, employees, agents, or T. Rowe Price’ s clearing broker, relating to the Account Agreements, this account and all accounts with Price, or transactions, or in any way arising from my brokerage relationship with T. Rowe Price, whether entered into prior to, on, or subsequent to this date. Such arbitration will be conducted before and according to the arbitration rules of the Financial Industry Regulatory Authority, Inc. (FINRA), unless the choice of another arbitrator forum is required by applicable state law. I understand that this predispute arbitration clause does not apply to any controversy or transaction involving T. Rowe Price funds unless they are held in my Brokerage Advantage account.

This agreement contains a predispute arbitration clause. By signing an arbitration agreement, the parties agree as follows:

1. All parties to this agreement are giving up the right to sue each other in court, including the right to a trial by jury, except as provided by the rules of the arbitration forum in which a claim is filed.

2. Arbitration awards are generally final and binding; a party’s ability to have a court reverse or modify an arbitration award is very limited.

3. The ability of the parties to obtain documents, witness statements, and other discovery is generally more limited in arbitration than in court proceedings.

4. The arbitrators do not have to explain the reason(s) for their award.

5. The panel of arbitrators will typically include a minority of arbitrators who were or are affiliated with the securi-ties industry.

6. The rules of some arbitration forums may impose time limits for bringing a claim in arbitration. In some cases, a claim that is ineligible for arbitration may be brought in court.

7. The rules of the arbitration forum in which the claim is filed, and any amendments thereto, shall be incorporated into this agreement.

8. No person shall bring a putative or certified class action to arbitration or seek to enforce any predispute arbitration agreement against any person who has initiated in court a putative class action or who is a member of a putative class action who has not opted out of the class with respect to any claims encompassed by the putative class action until: (i) the class certification is denied, (ii) the class is decertified, or (iii) the customer is excluded from the class by the court. Such forbearance to enforce an agreement to arbitrate shall not constitute a waiver of any rights under this agreement except to the extent stated herein.

Owner’S Signature (exactly as name appears in Section 1) Date

T. Rowe Price Brokerage is a division of T. Rowe Price Investment Services, Inc., member FINRA/SIPC. Brokerage accounts are carried by Pershing LLC (Pershing), a subsidiary of the Bank of New York Mellon Corporation, member NYSE/FINRA/SIPC. T. Rowe Price mutual funds not held as positions in your Brokerage account are serviced by T. Rowe Price Services, Inc., and are not carried by Pershing.

7 Signature (Continued)

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