Citibank IRA Transfer and Direct Rollover Form

Enclosed please find your requested Individual Retirement Account (IRA) documents for you to complete and

return. Unless you have already converted to simplified banking, by returning the enclosed documents for the

below-listed actions, you will initiate Early Access to convert any eligible deposit and investment accounts you

currently own to simplified banking.

• Opening a new Traditional or Roth IRA.

• Opening a new Certificate of Deposit (CD) account or Insured Money Market Account (IMMA) within an

existing IRA.

If you choose not to proceed at this time, you can convert later by initiating Early Access or you will be converted

by Citibank pursuant to a separate notice in 2024.

Please note: Uniform Transfers to Minors Act (UTMA) / Uniform Gifts to Minors Act (UGMA) accounts, and

Special Title accounts, and their beneficial owners, are ineligible for Early Access.

About simplified banking:

• Citibank’s simplified banking will transform the way you bank. We are enhancing the customer experience,

which includes changing how you receive benefits and features, automatically linking eligible accounts you

own, simplifying our checking products and providing you with different opportunities to waive Monthly

Service Fees.

As part of these changes, we are eliminating Account Packages.

If you meet the qualifying

Balance Ranges, you will enjoy the benefits of the Citi Priority, Citigold® and Citigold® Private Client

Relationship Tiers.

Please note that IRAs do not have Monthly Services Fees and will be unaffected by this particular change.

IRA account customers with no other deposit accounts are in the Citibank Account Package.

• You can convert to simplified banking before your conversion date by initiating Early Access. Before you

choose Early Access or engage in activities that will initiate Early Access, learn more about how simplified

banking will impact you and your accounts by speaking to a banker or by viewing your simplified banking

snapshot and Early Access at citi.com/earlyaccess. Please note, once you convert to simplified banking, your

accounts cannot return to an Account Package.

Here’s how conversion works:

• Customers in the Citibank Account Package will immediately join Relationship Tiers if they have at least

$30,000 in combined average monthly balances (CAMB) in the month prior to conversion.

• Customers with accounts in the Citi Priority, Citigold and Citigold Private Client Account Packages on their

conversion date will remain in Relationship Tiers by the same name unless they meet a higher CAMB Balance

Range in the month prior to conversion.

• Customers may be converted to a Legacy Relationship as defined in the Citi Consumer Deposit Account

Agreement (“CMA”). You will be notified after conversion if a Legacy Relationship applies to your accounts.”

For more information

The Client Manual — Consumer Accounts and Marketplace Addendum (“CMMA”) applies to existing non-

retirement Citibank accounts that have not been converted to simplified banking. The Consumer Deposit

Account Agreement (“CMA”) applies to accounts in simplified banking. Terms, conditions and fees for accounts,

products, programs and services are subject to change. Agreements are subject to change without notice unless

required by law and amendments will be made available to you. You can obtain copies of the current CMA and

CMMA online at citi.com/accountagreementsandnotices and copies of the CMA in Citibank branches.

If you have any questions, please do not hesitate to contact your local branch or call 1-800-321-CITI (For TTY:

We accept 711 or other Relay Service).

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What you need to Know

Please use this form to transfer an IRA that you have at another financial institution to a Citibank IRA.

Please review the information below before you complete this form.

Transfers

To transfer an IRA, Roth IRA, SEP-IRA, Inherited IRA or Inherited Roth IRA that you have at another financial institution to a

Citibank Traditional IRA, Roth IRA, SEP-IRA, Inherited IRA or Inherited Roth IRA (“Citibank IRA”), please follow these steps:

• To help identify your account, please include a copy of your most recent account statement (less than 90 days old) from your

current institution.

• Complete Sections 1 and 3 of the Citibank IRA Transfer and Direct Rollover Form.

(Note: Non-spouse IRA Beneficiaries must first have inherited funds moved to a Inherited IRA or Inherited Roth IRA in their name at

the current institution, prior to requesting the transfer.)

• If you do not select an IRA investment option in Section 3, funds will be placed in an Insured Money Market (“IMMA”) account.

Please refer to your Citibank IRA Plan Documents. Citibank can hold contribution funds uninvested or deposit funds in a Citibank

IMMA account if you do not provide clear written directions by the time Citibank receives the funds or in order to process certain

transactions including requests from you, a beneficiary, a local state or federal governmental entity or other authorized party.

• Certificates of Deposit (“CD”) and IMMA accounts will receive the interest rate in effect when Citibank receives the funds. Refer to

the IRA account Product section of the IRA Account Supplement for details. For current Annual Percentage Yields and interest rates

for CD and IMMA accounts in a Citibank IRA, visit citi.com, speak to a banker in a Citibank branch, or call Retirement Plan Services.

• Carefully read Section 4 before signing. If you do not have an existing Citibank IRA, Roth IRA, Rollover IRA, SEP-IRA,

Inherited IRA, or Inherited Roth IRA you must also complete the corresponding Citibank IRA Application.

• Please read and keep all documents below with your important records:

• If enrolled under a Traditional IRA Plan, please visit: citi.com/TraditionalIRAplan; for Roth IRA visit: citi.com/RothIRAplan

• Addendum to the Citibank Retirement Plan Documents and Coverdell Education Savings Account —

Cost of Living Adjustment (COLA) Information, please visit:

citi.com/AddendumCOLAInformation

• Consumer Deposit Account Agreement, please visit: citi.com/ConsumerDepositAccountAgreement

• Privacy Notice, please visit: citi.com/ConsumerPrivacyNotice

• Return the completed form(s) to any Citibank branch or mail the form(s) to:

Retirement Plan Services, Attn: Transfer Department; PO Box 769001, San Antonio, TX 78245-9951

For overnight delivery, send to: Retirement Plan Services, 100 Citibank Drive, San Antonio, TX 78245

Direct Rollovers

When you leave an employer and want to arrange a direct rollover of qualified plan assets to a Citibank IRA, please follow these steps:

• To help identify your account, please include a copy of your most recent account statement (less than 90 days old) from your

current institution.

• Contact your employer to let them know the amount of your plan assets you want rolled over to a Citibank IRA.

• Verify whether or not your employer requires that their own distribution form and/or an “acceptance letter” be used to request the rollover.

• Complete Sections 2 and 3 of the Citibank IRA Transfer and Direct Rollover Form. If you do not select an IRA investment option in

Section 3, funds will be placed in an Insured Money Market (“IMMA”) account. Please refer to your Citibank IRA Plan Documents.

Citibank can hold contribution funds uninvested or deposit funds in a Citibank IMMA account if you do not provide clear written

directions by the time Citibank receives the funds or in order to process certain transactions including requests from you, a

beneficiary, a local state or federal governmental entity or other authorized party.

• Certificates of Deposit (“CD”) and IMMA accounts will receive the interest rate in effect when Citibank receives the funds. Refer to

the IRA account Product section of the IRA Account Supplement for details. For current Annual Percentage Yields and interest rates

for CD and IMMA accounts in a Citibank IRA, visit citi.com, speak to a banker in a Citibank branch, or call Retirement Plan Services.

• Carefully read Section 4 before signing. If you do not have an existing Citibank IRA, Roth IRA, Rollover IRA, SEP-IRA,

Inherited IRA, or Inherited Roth IRA you must also complete the corresponding Citibank IRA Application.

06/23 RPS512 Page 1 of 6

• Please read and keep all documents below with your important records:

• If enrolled under a Traditional IRA Plan, please visit: citi.com/TraditionalIRAplan; for Roth IRA visit: citi.com/RothIRAplan

• Addendum to the Citibank Retirement Plan Documents and Coverdell Education Savings Account —

Cost of Living Adjustment (COLA) Information, please visit:

citi.com/AddendumCOLAInformation

• Consumer Deposit Account Agreement, please visit: citi.com/ConsumerDepositAccountAgreement

• Privacy Notice, please visit: citi.com/ConsumerPrivacyNotice

• Return the completed form(s) to any Citibank branch or mail the form(s) to:

Retirement Plan Services, Attn: Transfer Department, PO Box 769001, San Antonio, TX 78245-9951

For overnight delivery, send to: Retirement Plan Services, 100 Citibank Drive, San Antonio, TX 78245

• Citibank will contact your employer directly to arrange for your direct rollover. Your employer will be instructed to send a check

payable to Citibank, N.A., as Successor Custodian for your IRA, for the requested amount of your direct rollover.

If you have any questions

Call Retirement Plan Services at 1-800-695-5911. * For TTY: we accept 711 or other Relay Service. Representatives are available to

assist you Monday through Friday 8:00 a.m. – 10:00 p.m. Eastern Time, and Saturday 9:00 a.m. – 5:30 p.m. Eastern Time.

* To ensure quality service, calls are recorded

06/23 RPS512 Page 2 of 6

The Citibank IRA Transfer and Direct Rollover Form

PLEASE ATTACH A COPY OF YOUR MOST RECENT ACCOUNT STATEMENT (LESS THAN 90 DAYS OLD) FROM YOUR CURRENT

INSTITUTION. If you do not have an existing Citibank IRA, Roth IRA, Rollover IRA, SEP-IRA, Inherited IRA or Inherited Roth IRA

you must also complete the corresponding Citibank IRA Application.

1. To Transfer Assets from Another Institution

Please note: Transfers of securities will not be accepted. Securities intended for transfer must be liquidated prior to transfer.

Plan Number at Current Trustee:

______________________________________________

Plan Owner Name: __________________________________________________________ Social Security Number: ______________________________

Current Trustee: ____________________________________________________________________________________________________________________

Trustee Address: _________________________________________________________________________________________________________________

City: ____________________________ State: ___________________________Zip: __________________ Phone: ______________________________

By providing a phone number, you agree that we or our service providers can contact you at that number by text message, artificial

voice, pre-recorded or autodialed calls. Your phone plan charges may apply.

Transfer From/To (please check one):

a.  IRA to IRA  Roth IRA to Roth IRA  SEP-IRA to SEP-IRA

 Rollover IRA to Rollover IRA  Roth Conversion IRA to Roth Conversion IRA

Note: For Inherited IRA/Inherited Roth IRA plans, please complete section 1b. We must receive a Death Certificate photocopy.

b.  Inherited IRA to Inherited IRA  Inherited Roth IRA to Inherited Roth IRA

 Original plan holder’s Date of Birth: Month:

__________________________ Day: ____________ Year: _______________

 Original plan holder’s Date of Death: Month: _________________________Day: ____________ Year: _______________

What would you like to transfer?

Please Note: There may be penalties if you terminate a Certificate of Deposit (CD) before maturity.



100% of the plan  Less than 100% of the plan (specify dollar amount): $ __________________________

From account number: ___________________________________________________ If a CD, transfer:  Immediately  At Maturity

(There may be early withdrawal penalties if you terminate a CD before maturity.)

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2. Direct Rollover of Assets from an Employer’s Qualified Plan

Please note: Direct rollovers of securities will not be accepted. Securities intended for direct rollover must be liquidated prior

to rollover.

Plan Owner Name:

_________________________________________________________ Social Security Number: ______________________________

Employer Name: ___________________________________________________________________________________________________________________

Address: _________________________________________________________________________________________________________________________

City: ____________________________ State: ___________________________Zip: __________________ Phone: ______________________________

By providing a phone number, you agree that we or our service providers can contact you at that number by text message, artificial

voice, pre-recorded or autodialed calls. Your phone plan charges may apply.

Direct Rollover From/To (please check one):

a.  401(k) Plan to IRA  403(b) Plan to IRA  457 Plan to IRA  Money Purchase Keogh Plan to IRA

 401(k) Plan to SEP-IRA  403(b) Plan to SEP-IRA  457 Plan to SEP-IRA  Profit Sharing Keogh Plan to IRA

 401(k) Plan to Roth IRA  403(b) Plan to Roth IRA  457 Plan to Roth IRA  Roth 401(k) Plan to Roth IRA

 Roth 457 Plan to Roth IRA  Roth 403(b) Plan to Roth IRA  Money Purchase Keogh Plan to Roth IRA

Profit Sharing Keogh Plan to Roth IRA

Note: For Inherited IRA/Inherited Roth IRA plans, please complete section 1b. We must receive a Death Certificate photocopy.

b.  401(k) Plan to Inherited IRA  403(b) Plan to Inherited IRA  457 Plan to Inherited IRA

Money Purchase Keogh Plan to Inherited IRA Roth 401(k) Plan to Inherited Roth IRA

 Roth 403(b) Plan to Inherited Roth IRA  Roth 457 Plan to Inherited Roth IRA

 Original plan holders Date of Birth: Month: ___________________________Day: ____________ Year: _______________

 Original plan holders Date of Death: Month: __________________________Day: ____________ Year: _______________

How much would you like us to collect from your retirement plan? Date of Direct Rollover:



100% of the amount that is eligible for a direct rollover  Collect the Direct Rollover immediately

 Less than 100%. (specify dollar amount): $

_____________________  Collect the Direct Rollover on (date): _________________

3. Select An Investment Option Into Which Funds Will Be Transferred/Rolled Over

If no investment is selected, funds will be placed in an Insured Money Market (“IMMA”) account. Please refer to your Citibank IRA Plan

Documents. Citibank can hold contribution funds uninvested or deposit funds in a Citibank IMMA account if you do not provide clear

written directions by the time Citibank receives the funds or in order to process certain transactions including requests from you, a

beneficiary, a local state or federal governmental entity or other authorized party.

Certificates of Deposit (“CD”) and IMMA accounts will receive the interest rate in effect when Citibank receives the funds. Refer to the

IRA account Product section of the IRA Account Supplement for details. For current Annual Percentage Yields and interest rates for CD

and IMMA accounts in a Citibank IRA, visit citi.com, speak to a banker in a Citibank branch, or call Retirement Plan Services.

 CD

Term Amount  Insured Money Market (IMMA) account

_________________ $ _______________ $ ____________________

(Minimum Investment $250)

Plan Number: _______________________________________________________________

Account Number: ___________________________________________________________

(if existing account)

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4. Acceptance

By signing below, I authorize, certify and/or acknowledge that:

• I have read and understand all the information provided and as outlined in this form.

• If this request requires a new deposit account: I have read and agree to the terms of the Consumer Deposit Account Agreement (“CMA”),

which applies to accounts in simplified banking. Unless I have already converted to simplified banking, by choosing to proceed with

the request on this form, Early Access will be initiated to convert any Citibank accounts I own to simplified banking. When converted to

simplified banking, I may be converted to a “Legacy Relationship” and may become eligible for a “Relationship Tier” as defined in the CMA.

• If I was converted to a Legacy Relationship when converted to simplified banking, I have now either converted to a “Family Link” or

have opted out of the Legacy Relationship.

• If this request applies to an existing Citibank Traditional/Roth IRA: I have received the updated applicable Traditional/ Roth

Individual Retirement Custodial Account Agreement (“Custodial Agreement”) and the applicable Traditional/Roth IRA Disclosure

Statement that includes the IRA Financial Disclosure (“Disclosure Statement”), that amends and restates the previously provided

Custodial Agreement and Disclosure Statement applicable to my Citibank Traditional/Roth IRA.

• I authorize Citibank to contact the financial institution or employer named above on my behalf, to request remittance of the IRA or

retirement plan assets described above to Citibank, N.A. as successor custodian.

• I understand the financial institution named above may assess an early withdrawal penalty for Certificate of Deposit accounts

terminated prior to the maturity date.

• Citibank will send written notice confirming the applicable request. Any discrepancies or errors in any notice about my Citibank

Traditional/Roth IRA must be reported to Citibank within 60 days of the notice date.

• I cannot revoke any election to have a contribution treated as a rollover.

• Only eligible rollover distributions can be treated as direct rollovers.

• If this request requires a new deposit account: I have received, read, and agree to the terms of the IRA Account Supplement to the

Consumer Deposit Account Agreement (“IRA Account Supplement”) applicable to the deposit account type(s) selected.

• Insured Money Market (“IMMA”) accounts and Certificate of Deposit (“CD”) accounts are deposit products offered by Citibank, N.A.

Member FDIC.

• Citibank can hold contribution funds uninvested or deposit funds in a Citibank IMMA account if I do not provide clear written

directions by the time Citibank receives the funds or in order to process certain transactions including requests from me, a

beneficiary, a local state or federal governmental entity or other authorized party.

• IMMA accounts and CDs will receive the interest rate in effect when Citibank receives the funds. Please refer to the IRA account

Products section of the IRA Account Supplement for details. For current Annual Percentage Yields and interest rates for IMMA

accounts and CD accounts in a Citibank IRA, visit citi.com, speak to a banker at a Citibank branch, or call Retirement Plan Services.

• If this request requires a new deposit account: During a new account application process, Citibank may verify my identity using

commercially available databases containing information from public records, other financial institutions and consumer

reporting agencies.

This form must be received within 90 days of the date of your signature. If the form is received after 90 days of your dated signature,

Citibank will request a new form to be completed.

► Owner’s Signature: __________________________________________________________________ Date: ______________________________________

All requests must include one of the following:

Medallion Signature Guarantee, Signature Verification or Notary Stamp (see page 5 of this document)

Please make checks payable to Citibank, N.A. as Successor Custodian and deliver to:

Retirement Plan Services, attn: Transfer Department; PO Box 769001, San Antonio, TX 78245-9951

BRANCH USE ONLY. The below information is required when this form is submitted by branch personnel.

Representative Name: ______________________________________________________

SOEID:

__________________________________

Date:

____________________________________

Citibank RPS Use Only — Directions and Information for Financial Institution Named Above

Citibank, N.A. accepts its appointment as successor custodian for the transfer described above.

Citibank, N.A. Authorized Signature/Stamp:__________________________________________ Date:

______________________________________

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Page 5 of 6

California Only

Acknowledgment

A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document

to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.

Stat

e of California

County of___________________________________________

On__________________________________ before me, __________________________________________personally appeared

(date) (here insert name and title of the officer)

_____________________________________________________ who proved to me on the basis of satisfactory evidence to be the person

whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her authorized

capacity, and that by his/her signature on the instrument the person, or the entity upon behalf of which the person acted,

executed the instrument.

I certify under PENALTY OF PERJURY under the laws of the state of California that the foregoing paragraph is true and correct.

WITNESS my hand and official seal.

► _________________________________________________________

Notary Public Signature (Notary Public Seal)

All States Except California

Acknowledgment

State of __________________________________________________

County of_________________________________________________

On_______________________________ before me personally appeared, __________________________________________________

(date)

personally known to me or proved to me on the basis of satisfactory evidence

(Type of Identification produced

__________________________________________________ ) to be the individual whose name is subscribed to

the within instrument and acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature on

the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument.

► _________________________________________________________

Notary Public Signature

_____________________________________________________________

Notary Public Printed Name (Notary Public Seal)

06/23 RPS512

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