Roth IRA Conversion form

Sep 19, 2026

Roth IRA Conversion form用于将既有Traditional IRA或SEP IRA的全部或部分转换为Roth IRA。表格说明全额与部分转换的合同编号保留规则，并提示73岁及以上可能需先办理RMD。文件强调转换属于应税事件、转换后将按转换当年计入收入，并要求妥善保存转换记录以便申报税务。表单还规定预扣税的选择方式、费率范围、州税预扣选项以及签署确认、欺诈声明与合规填写要求。

LanguageEnglish

CategoryForms

FormatPDF

Pages4

Reading Time2 min

AccessFree to download

Instructions

1. Contract information

2. Conversion

3. Important tax withholding information

4. Federal election of withholding

5. State election of withholding

6. Acknowledgement, Fraud statements and signature

Roth IRA Conversion form CLEAR ALL P.O. Box 14432, Des Moines, IA 50306-3432 Instructions Use this form to convert all or part of your existing Traditional IRA or SEP IRA to a Roth IRA. Partial Roth conversions are only available on Contracts issued in February 1, 2024 or later. • If a full conversion is selected, you will retain the same Contract number. Only the tax status of the Contract will change, all other contractual terms and conditions will remain the same. • If a partial conversion is selected, you will retain the same Contract number for IRA funds and you will receive an additional Contract number for the converted amount. All other contractual terms and conditions will be identical to your IRA Contract listed below. • If age 73 or older, you may need to have any Required Minimum Distribution (RMD) processed before requesting a full Roth IRA conversion. • You are responsible for maintaining records of your Roth IRA conversions and annual contributions in order to properly complete your tax returns. • Please ensure pages 1 and 2 of this form are submitted and all sections are completed accurately to ensure prompt processing of your request. Conversions are final and will be reported as income in the tax year they are converted. 1. Contract information Annuity Policy/Contract number | Owner’s name (first, middle initial, last) | Social Security number | | --- | --- | 2. Conversion Conversions are a taxable event-please consult your tax professional. Full Roth IRA Conversion – By marking this box I request to convert the current balance of my existing IRA to a Roth IRA. Partial Roth IRA Conversion – By marking this box I request to convert the below amount of my existing IRA to a Roth IRA. $ Net Gross Selecting Net or Gross will only apply if you have elected tax withholding. By selecting Net, the taxes will come out in addition to the amount indicated for the conversion. By selecting Gross, the amount of the conversion will be reduced by the taxes. 3. Important tax withholding information • Any taxes withheld on a Roth IRA conversion will be considered a partial withdrawal from the non-Roth IRA account, and will not be included as part of the conversion. • Any withdrawal amount processed to satisfy withholding will be reported as a taxable distribution in the year they are withheld, and may be subject to a 10% penalty if you are under age 59 1/2 at the time of the conversion. • The amount of withholding is calculated based on the amount converted at the time of the conversion and cannot exceed the penalty free amount available on the Contract. • Any withdrawal of funds to satisfy the withholding will reduce the amount of proceeds paid upon full withdrawal, payment of any death benefits, or annuitization. If your Contract includes an Income Benefit or Rider, it may be negatively impacted by a withdrawal. Funds withdrawn from fixed index annuities will be removed pro-rata from each fixed/index account allocation and any strategy fees will be assessed at the time of the withdrawal if the withdrawal amount exceeds the contractual Penalty Free provisions. • Your withdrawal provisions can be found on the specification page of your Contract. 4. Federal election of withholding See the instructions on pages 3-4 and Marginal Rate Tables for additional information. Your withholding rate is determined by the type of payment you will receive. • The default withholding rate is 10%. You can choose to have a different rate by entering a rate between 0% and 100% . Generally, you cannot choose less than 10% for payments to be delivered outside the United States and its territories. I would like a default federal withholding rate. I would like a federal rate of withholding that is different from the default withholding rate. % Enter the rate (percent) as a whole number (enter a rate between 0% and 100%, no decimals) North American Company for Life and Health Insur

FAQs

本表用于什么目的？

用于将既有的Traditional IRA或SEP IRA的全部或部分转换为Roth IRA。部分转换仅适用于2024年2月1日或之后签发的合同。

全额转换与部分转换在合同编号上有什么区别？

全额转换选定后保留相同合同编号，合同的税务状态会改变。部分转换选定后，IRA资金保留同一合同编号，但转换金额将获得额外的合同编号。

Roth IRA转换和预扣税有哪些关键税务提示？

转换属于应税事件，转换将作为收入计入转换发生的税年。若发生预扣税，该预扣将被视为非Roth账户的部分提款，并可能在年龄59岁半以下时面临10%罚金。

Sep 19, 2026

Upload by Alex Sinclair