1 of 3Customer Service: 800-747-2537

Capital One Investing, LLC, PO Box 259008, Plano, TX 75025Conversion from a Traditional IRA to a Roth IRA

Conversion from a Traditional IRAto a Roth IRA

Account Name

Date of Birth

Account Number (Traditional IRA)

Account Number (Roth IRA)

SSN

Account Information

1

2

Complete each section and sign form.

Fax or mail this form to the address listed below.

Mail document to:Capital One Investing, LLCPO Box 259008Plano, TX 75025

Fax document to:Our fax number (Available 24hr per day)888-389-1025

Convert assets to the following Capital One Investing account:

Convert the following assets:

Directly convert all of my Traditional IRA assets to my Roth IRA.

Directly convert only the Traditional IRA assets shown below to my Roth IRA.

Asset Description (Cash or Stock Symbol) Quantity / Amount to Convert

Please convert the assets from the following account:

Is this a Capital One Advisors Managed Portfolios account? 1

Is this a Capital One Advisors Managed Portfolios account? 1 Yes

Yes

No

No

2 of 3Customer Service: 800-747-2537

Capital One Investing, LLC, PO Box 259008, Plano, TX 75025Conversion from a Traditional IRA to a Roth IRA

I elect to have no Federal tax withholding.

I elect to have no State tax withholding.

I elect to have Federal tax withholding taken at the standard rate of 10%.

I elect to have State tax withholding taken at the required rate*.

I elect to have Federal tax withholding taken of $___________________.(This amount must be greater than 10%.)

I elect to have State tax withholding taken of $____________________.*

Federal Withholding Election: (Select one)The Tax Equity and Fiscal Responsibility Act of 1982 requires withholding of Federal Income Taxes from distributions beginning on January 1, 1983, unless the recipient elects not to have withholding apply. You may elect out of this withholding by checking the appropriate box below. If no election is made, the trustee must withhold taxes at the required rate. If you are subject to the estimated tax rules and your withholding and/or estimated tax payments are not sufficient, penalties may be incurred. (All withholding will be deducted from the gross distribution amount prior to issuing the funds to you.)

State Withholding Election: (Select one, if applicable)Certain states require withholding for state tax. If no election is made, we are required to automatically withhold a certain amount depending on your state of residence. (*Please refer to the state tax withholding reference chart for your state’s withholding requirements.)

I certify that I am eligible for this conversion:

I hereby irrevocably designate this contribution in cash and/or property as a conversion contribution. I have read and understand the conversion rules and conditions and I have met the requirements for making a conversion. Due to the important tax consequences of converting funds or property to a Roth IRA, I have been advised to see a tax professional. All information provided by me is true and correct and may be relied upon by the trustee. I assume full responsibility for the conversion transaction and will not hold the Trustee liable for any adverse consequences that may result.

Withholding Elections

Eligibility Certification

Account Name Account Number

Signature

Date

X

Signature guarantee or notary

1. If I am 70 ½ or older in this calendar year, the conversion does not contain any amounts which constitute a required minimum distribution from the distributing plan.

2. If I am married, my spouse and I file a joint federal income tax return for the year in which this distribution occurs. 3. If this is a re-conversion of a prior conversion, it is within the same taxable year of the prior conversion or, if later it is within 30 days of

re-characterizing a prior conversion.4. No more than 60 days have elapsed since I received the distribution from the distributing IRA.

Investment products are offered by Capital One Investing, LLC, a registered broker-dealer and Member FINRA/SIPC. Investment advisory services are provided by Capital One Advisors, LLC,

an SEC-registered investment advisor. Insurance products are offered through Capital One Agency, LLC.

All are subsidiaries of Capital One Financial Corporation.

All the necessary requirements to open an account must be met.

1 We’ll attempt to generate the amount requested, subject to market conditions.

IRA State Tax Withholding and Required Rate Reference Chart:*State tax withholding can only be taken if Federal tax withholding has been elected. These withholding guidelines are included for reference only and are subject to change at any time.

State Withholding RequirementsAlabama N / AAlaska N / AArizona N / AArkansas N / ACalifornia You must withhold 10% of the federal withholding amount unless you specify another amount (zero is not allowed)Colorado N / AConnecticut N / ADelaware N / ADistrict of Columbia N / AFlorida N / AGeorgia You must withhold 5% of the gross distribution amount unless you elect to have no state tax withholding takenHawaii N / AIdaho N / AIllinois N / AIndiana N / AIowa You must withhold 5% of the gross distribution amountKansas You must withhold 5% of the gross distribution amount unless you elect to have no state tax withholding takenKentucky N / ALouisiana You must withhold 3% of the gross distribution amount unless you elect to have no state tax withholding takenMaine You must withhold 5% of the gross distribution amountMaryland You may elect to have any amount withheld for state tax withholding (including none)Massachusetts You must withhold 6% of the gross distribution amountMichigan N / AMinnesota N / AMississippi N / AMissouri N / AMontana N / ANebraska N / ANevada N / ANew Hampshire N / ANew Jersey You may elect to have any amount withheld for state tax withholding (including none)New Mexico N / ANew York You may elect to have any amount withheld for state tax withholding (including none)North Carolina You must withhold 4% of the gross distribution amountNorth Dakota N / AOhio N / AOklahoma You must withhold 7% of the gross distribution amount unless you specify a greater amount to withholdOregon You must withhold 8% of the gross distribution amount unless you elect to have no state tax withholding takenPennsylvania N / ARhode Island N / ASouth Carolina N / ASouth Dakota N / ATennessee N / ATexas N / AUtah N / AVermont You must withhold 24% of the federal withholding amount unless you elect to have no state tax withholding takenVirginia You may elect to have any amount withheld for state tax withholding (including none)Washington N / AWest Virginia N / AWisconsin N / AWyoming N / A

3 of 3Customer Service: 800-747-2537

Capital One Investing, LLC, PO Box 259008, Plano, TX 75025Conversion from a Traditional IRA to a Roth IRA