BMO FUNDS ROTH IRA CONVERSION FORM

BMO FUNDS ROTH IRA CONVERSION FORM
For help with this form, or for more information, call us toll-free at 1-800-236-FUND(3863) or 414-287-8555.
Please complete this form when converting a Traditional IRA to a Roth IRA. If needed, complete and include a Roth IRA Application with this form.
NOTE: In order to qualify for a conversion to the Roth IRA, your adjusted gross income for filing a joint or single tax return must be within the current IRS
limits. If you are married and filing a separate tax return, you are NOT eligible to convert to the Roth IRA.
1. Registration and Mailing Address
_______________________________________________________________________________________________________________
Name (first, middle initial, last)
_________________________________________________________ Social Security Number
___________________________________________________
Birth Date
_______________________________________________________________________________________________________________
Street Address
_________________________________________________________ City
_______________________ State
_________________________
Zip Code
_________________________________________________________ Email Address
_______________________ Daytime Phone
_________________________
Evening Phone
2. Existing Account Information
Choose one of the following:
o A. Conversion from an existing BMO FUNDS IRA account
_______________________________________________________ Account Number
___________________________________________________
Account Owner’s Name
$______________________________________________________ o Amount to be Converted
Shares_____________________________________________
o Number of shares to be converted (if entire account, write ALL)
o B. Conversion from a NON-BMO FUNDS IRA account
_____________________________________________________________________________________________________________
Name of Current Custodian (bank, savings and loan, mutual fund, etc.)
_________________________________________________________________________________ Address
_________________________
P.O. Box
_______________________________________________________ City
_________________________
Zip Code
_____________________________________________________________________________________________________________
Account Name
_____________________________________________________________________________________________________________
Account Number or Certificate of Deposit Number and Maturity Date (if applicable)
_________________________________________________________________________________ Custodian Contact Person
_______________________ State
_________________________
Custodian Phone
o C. Conversion to a Roth IRA as a result of a distribution from a Traditional IRA within the past 60 days.
If you choose this option, you may skip sections 3 and 4.
o I have received a distribution from a Traditional IRA that I elect to roll over and convert into a Roth IRA.
(12-23-14)
Page 1 of 4
3. Withholding Election for Conversion
IRS regulations require the Custodian of the IRA from which you are converting to withhold federal income taxes at the rate of 10% from the
converted amount unless you elect not to have withholding apply. Withholding will apply to the entire amount of the conversion, even if nondeductible contributions to the IRA have been made. You may still reinvest the entire conversion amount by replacing the amount withheld
with other assets. Any amounts withheld and not replaced into the new BMO Funds Roth Conversion IRA within 60 days may be subject to a
10% early withdrawal penalty if you are under age 59 ½ years old.
o I do not want federal income tax withheld from this conversion.
o I want to have federal income tax of 10% withheld from this conversion.
o I want __________% (more than 10%) withheld for federal income tax from this conversion.
o I want $_________ withheld for state income tax from this conversion.
4. To Current IRA Custodian (NON-BMO FUND IRAs ONLY)
Please consider this your authorization to send my IRA proceeds to BMO Funds. Please sell all assets immediately if no selection is
checked below:
1.Please SELL
o all, or o partial $_______________ or __________% of my assets in the account referenced in section 2.
(Please provide this figure as a dollar amount or as a percentage of the total value of your distribution.)
2. Please SELL o immediately, or o at maturity, maturity date ____/____/____.
NOTE: There may be penalties for withdrawing certain investments before their maturity. Please contact your current custodian to
determine the applicable penalty, if any. Please send all conversion requests two weeks before maturity to ensure a timely conversion.
If you are over 70½, your Required Minimum Distribution (RMD) is NOT eligible to be converted to the Roth IRA.
5. BMO Fund(s) Allocation
Select one of the following:
o New Account – Please complete a BMO Funds IRA New Account Application (the funds and allocations specified on the New Account
Application will be used).
o Existing Account – Account Number _____________________________________________
Please indicate the funds and allocations you would like below:
BMO Low Volatility Equity Fund (1049/1050)
$_________________
________________ %
BMO Large-Cap Value Fund (260/926) $_________________
________________ %
BMO Dividend Income Fund (1039/1040)
$_________________
________________ %
BMO Large-Cap Growth Fund (206/927)
$_________________
________________ %
BMO Mid-Cap Value Fund (262/931) $_________________
________________ %
BMO Mid-Cap Growth Fund (261/963)
$_________________
________________ %
BMO Small-Cap Value Fund (1037/1038)
$_________________
________________ %
BMO Small-Cap Growth Fund (612/964)
$_________________
________________ %
BMO Small-Cap Core Fund (1121/1122)
$_________________
________________ %
BMO Micro-Cap Fund (1097/1098)
$_________________
________________ %
BMO Global Low Volatility Equity Fund (1099/1100) $_________________
________________ %
BMO Pyrford International Stock Fund (1045/1046)
$_________________
________________ %
BMO LGM Emerging Markets Equity Fund (752 /754)
$_________________
________________ %
BMO Pyrford Global Equity Fund (1123/1124)
$_________________
________________ %
BMO Short-Term Income Fund (203/993)
$_________________
________________ %
BMO TCH Intermediate Income Fund (204/995)
$_________________
________________ %
BMO Mortgage Income Fund (207/968)
$_________________
________________ %
BMO TCH Corporate Income Fund (798/799) $_________________
________________ %
BMO TCH Core Plus Bond Fund (756/796)
$_________________
________________ %
BMO Monegy High Yield Bond Fund (1041/1042)
$_________________
________________ %
BMO TCH Emerging Markets Bond Fund (1051/1052) $_________________
________________ %
BMO Multi-Asset Income Fund (1125/1126)
$_________________
________________ %
BMO Government Money Market Fund (604)
$_________________
________________ %
BMO Prime Money Market Fund (200/090) $_________________
________________ %
BMO Target Retirement 2010 Fund (1053/1054)
$_________________
________________ %
(12-23-14)
Page 2 of 4
5. BMO Fund(s) Allocation (continued)
BMO Target Retirement 2015 Fund (1101/1102)
$_________________
________________ %
BMO Target Retirement 2020 Fund (1057/1058)
$_________________
________________ %
BMO Target Retirement 2025 Fund (1105/1106)
$_________________
________________ %
BMO Target Retirement 2030 Fund (1061/1062)
$_________________
________________ %
BMO Target Retirement 2035 Fund (1109/1110)
$_________________
________________ %
BMO Target Retirement 2040 Fund (1065/1066)
$_________________
________________ %
BMO Target Retirement 2045 Fund (1113/1114)
$_________________
________________ %
BMO Target Retirement 2050 Fund (1069/1070)
$_________________
________________ %
BMO Target Retirement 2055 Fund (1117/1118)
$_________________
________________ %
BMO Conservative Allocation Fund (1073/1074)
$_________________
________________ %
BMO Moderate Allocation Fund (1077/1078)
$_________________
________________ %
BMO Balanced Allocation Fund (1081/1082)
$_________________
________________ %
BMO Growth Allocation Fund (1085/1086)
$_________________
________________ %
BMO Aggressive Allocation Fund (1089/1090)
$_________________
________________ %
$_________________
________________ %
100%
6. IRA Owner’s Signature
I hereby appoint State Street Bank and Trust Company as Custodian to my BMO Funds Roth Conversion IRA. I hereby authorize and request
the custodian or trustee of my IRA specified in Section 2 to make the requested distribution from my IRA and conversion contribution to my
BMO Funds Roth Conversion IRA. I hereby attest that for the year of the conversion, my AGI is within the current IRS limits and I accept full
responsibility for complying with all IRS rules on conversions. I hereby agree to indemnify the custodian (its agents, affiliates, successors
and employees) of my IRA, State Street Bank and Trust Company, BMO Funds and BMO Asset Management Corp. from any liability in the
event I fail to meet any of the IRS requirements.
I understand that I will be subject to income taxes on the amount converted from my IRA to a BMO Funds Roth Conversion IRA to the
extent that the converted amount is includable in my income (i.e., any tax-deductible contributions and any earnings). I understand the
taxable amount will be subject to taxes in the year in which the conversion occurs.
If I am over age 70½, I attest that I have satisfied (or will satisfy) the IRS minimum distribution requirements for the current year
pursuant to Section 401(a)(9) of the Internal Revenue Code with respect to my IRA, and I accept full responsibility for complying with
these requirements.
___________________________________________________________________________ __________________________________
Your Signature
Date
Medallion Guarantee
(Important: Please contact your current Custodian to determine if a medallion guarantee is required.)
(12-23-14)
Page 3 of 4
7. Mailing Information
Regular Mail:
BMO Funds
P.O. Box 55931
Boston, MA 02205-5931
Overnight Mail:
BMO Funds
c/o Boston Financial Data Services
Suite 55931
30 Dan Rd.
Canton, MA 02021
8. Custodian Acceptance
Please be advised that State Street Bank and Trust Company does hereby accept appointment as Custodian of the BMO Funds Roth
Conversion IRA.
___________________________________________________________________________ __________________________________
Authorized Signature
Date
Make check payable and forward to:
BMO Funds
FBO Shareholder’s Name
Account Number____________________________
P.O. Box 55931
Boston, MA 02205-5931
(12-23-14)
Page 4 of 4

Download Report