Roth Conversion Form - Victory Capital

Mutual Fund IRA Roth Conversion Form

Traditional, SEP and SIMPLE IRAs

First Name

MI

Last Name

Primary Phone Number (include area code)

Phone Type

Residence

Work

Cell

Type of Current Plan

Select funds to convert within this registration:

All Funds

Specific Funds

Note: Estimated conversion amount: $0.00

Distribution Instructions

If you need to open a new Victory account, please do so first by navigating to your Home page > Victory Funds > Open a Victory Funds Account. Once your account is open, return to this form to complete your request.

Maintain current investment choices.

Liquidate mutual funds held in the accounts designated above in the dollar amounts set forth and indicate new investment choices below.

In general, retirement distributions you receive are subject to federal and, in some states, state income tax. IRS Regulations require withholding of 10% federal income taxes from retirement distributions unless you provide a different election below. If no tax election is made, we are required to withhold 10% of your distribution for Federal Income Tax purposes (excluding Roth IRA distributions). Prior to making your federal income tax withholding election, refer to the Marginal Rate Tables and the General Instructions found in the attached IRS Form W-4R. You may use these tables to help you select the appropriate withholding rate for this distribution.

Please make your withholding election below rather than on Form W-4R.

Federal Tax Withholding Election (Select One)

I DO NOT want to have federal income tax withheld from my retirement plan distribution.

I DO want to have federal income tax withheld from my retirement plan distribution at the rate of

NOTE: The IRS Form W-4R is for information only. You are not required to complete the IRS Form W-4R.

State Tax Withholding Election (Select One)

If you reside in a certain mandatory withholding state, we are required to withhold state income tax at the rate prescribed by your state (excluding Roth IRA distributions). Some states require an additional form to be completed for your state withholding election. To ensure your distribution request is not delayed by required additional paperwork, if your state has state income tax, please contact Victory Funds to determine the requirements for your state. You may also contact your state or consult with a tax advisor regarding your specific situation.

If no state tax election is made, we will automatically apply state withholding (if required by your state) at the minimum rate based on your state of residency.

The state of residence in the legal address on this IRA will determine the state income tax withholding requirements for your distributions.

I DO NOT want to have state income tax withheld from my retirement plan distribution.

I DO want to have state income tax withheld in accordance with the minimum amount or percentage as determined by the requirements of my state of residence. If your state does not provide a minimum percentage no state income tax withholding will be withheld.

I DO want to have state income tax withheld from my retirement plan distribution (must be higher than the state minimum).

If no tax is withheld, you may still be subject to federal and state tax on this income. You may also be subject to IRS penalties under rules for estimated tax if your payments of estimated tax and federal/state tax withheld, if any, are not sufficient. Your withholding election will remain in effect until revoked by you.

I hereby direct Victory Funds to make the conversion described above from the IRA(s) referenced above. I understand and acknowledge that Victory Funds (including the Custodian of my IRA) will be acting solely on my representations and instructions as set forth in this form, and that Victory Funds (including the Custodian of my IRA) will not independently verify whether or not I qualify for the type or amount of conversion directed. I understand and acknowledge that I alone am responsible for all tax consequences that may result from performing such conversion and that I should seek the advice of an attorney or tax advisor regarding my specific situation.

IMPORTANT INFORMATION. The Tax Cuts and Jobs Act eliminated the ability to recharacterize any conversion made to a Roth IRA in 2018 or after. Any taxable amounts converted will be subject to federal income taxes in the year in which the conversion occurs. Therefore, you should consult your tax advisor regarding your specific situation prior to requesting a conversion.

Tools & Resources

Insights

Mutual Fund IRA Roth Conversion Form

Traditional, SEP and SIMPLE IRAs

Personal Information

From: Conversion Request

To: Conversion Request

Federal and State Tax Withholding

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