Riversource 30482 Form – Fill Out and Use This PDF

DOC010830482

RiverSource Life Insurance Company 70100 Ameriprise Financial Center Minneapolis, MN 55474

Outgoing Annuity Tax-Qualified Transfer, Exchange, Conversion or Direct Rollover from RiverSource Life Insurance Company

Part 1	RiverSource Life Account You Are Moving Assets From
Owner Name
Plan Type:
Traditional IRA (including Rollover and SEP)			Roth Contributory IRA	Simple IRA
Tax-Sheltered Annuity (TSA)			Roth Conversion IRA	Inherited (Beneficial) IRA
Amount to be moved:
Full (100%)		Specific Amount $

Part 2 Account You Are Moving Assets To

Company Name

Advisor/Agent Name

Owner Name

Product Name

Product Type
Fixed Annuity	Variable Annuity	Market Value Annuity	Equity Index Annuity	Immediate Annuity
Mutual Fund	CD	Brokerage	Other

Account You Are Moving Assets To continued on next page..

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Account You Are Moving Assets To continued

If product is an annuity (Select One):

New Contract	Existing Contract	Account Number
Plan Type:
Traditional IRA (including Rollover and SEP)		Inherited (Beneficial) IRA	Tax-Sheltered Annuity (TSA)
Roth IRA		457	Tax-Sheltered Custodial Account (TSCA)
Simple IRA		401(a)	Other

Delivery Instructions

Make check payable to:

Mail check to:

Address

City		State		ZIP code

Part 3 Plan Sponsor Information

		Employer Identification Number
Name of Plan Sponsor (Required)		(EIN) (Required)		Phone Number

Mailing Address (Required)

City		State		ZIP code

Part 4	Withholding Instructions

Direct Conversion from TSA to a Roth IRA

A direct conversion from a TSA to a Roth IRA results in income tax being due on the taxable portion of the transaction. Please see the Special Tax Notice for Plan Distributions. You should consult with a tax advisor prior to requesting this transaction. There will be no withholding on this request unless you elect withholding below.

Direct Conversion from a Traditional, SEP or SIMPLE IRA to a Roth IRA

If taxes are withheld from this distribution, the net conversion amount will be the gross amount requested - (minus) the tax withholding. If your annuity contract is subject to contractual surrender charges and you elect withholding, surrender charges will apply to the amount withheld.

Federal Withholding: You are liable for federal income tax on the taxable portion of your distribution. If total withholding is not adequate, you may be subject to estimated tax payments and/or penalties.

State Withholding: Withholding rules vary by state. Clients may have the option to: (1) opt-out withholding, (2) elect default state tax withholding, or (3) increase the rate of withholding. Depending on the state, state tax withholding could be mandatory, optional, unavailable, or the client may need to complete a state-specific form. For state tax withholding rules, go to riversource.com/statetax.

Please note that taxes withheld per your elections or in accordance with state rules will not be refunded.

Different withholding rules apply in certain situations: If we do not have a valid Taxpayer Identification Number on the account, if the payment is delivered outside the United States or if you are a non-resident.

Please consult your tax professional for additional information regarding federal and/or state withholding.

Withholding Instructions continued on next page..

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Withholding Instructions continued

Federal Withholding

Any amount withheld may result in a 10% IRS Premature Penalty Tax.

10% federal income tax will be withheld from the conversion amount unless you make a different withholding election below.

Do not withhold federal tax		Withhold 10% federal tax		Withhold		% federal tax - must be more than 10%

State Withholding

Do not withhold state tax

Withhold default state tax

Withhold

% state tax

Part 5 Acknowledgements and Signatures

Roth Conversion Only

I understand that by converting my account to a Roth IRA, I will owe income tax on all pre-tax assets converted. The decision of whether to convert my account to a Roth IRA was made in light of all relevant financial information and in conjunction with my professional tax advisors.

TSA Contracts Only

RiverSource Life Insurance Company does not transfer, exchange or rollover outstanding TSA loan balances. For TSA to TSA/TSCA transfers if there is an outstanding TSA loan balance, the transaction will be reduced to an amount that will maintain the loan balance on the account or maintain the minimum balance required to keep the account open, whichever is greater, and the balance of the account will be transferred/rolled over to the Company named in Part 2. To avoid this transaction reduction, the loan distribution must be approved by the plan administrator for the plan sponsor the account is associated with and the triggering event that was met must be indicated below. For rollovers from a TSA to a non- TSA/TSCA if there is an outstanding TSA loan balance, the loan will be surrendered; then any remaining funds will be transferred/rolled over to the Company named in Part 2. The surrender of the loan could create adverse tax consequences.

RiverSource Life Insurance Company requires full loan repayments to be at least 10 days old prior to a transfer or a rollover of the full account value. If this request is received within 10 days of a full loan repayment, the request will be processed on the date the loan repayment is 10 days old.

Distribution options available may be restricted by the applicable employer's 403(b) plan provisions. The Plan Administrator or Summary Plan Description are sources for further information.

Transfer: This transaction is intended to qualify as a Transfer. A Transfer occurs when an employee changes from one 403(b) investment option allowed under the plan to another investment option in the same plan.

Rollover: This transaction is intended to qualify as a Rollover. A Rollover occurs when an employee moves all or a portion

of their 403(b) account to another tax plan (i.e. Traditional IRA) or from one employer's 403(b) plan into investment products offered by a different employer's 403(b) plan.

Information Sharing Agreement: An agreement between the employer and the vendor allowing the exchange of information to ensure compliance with 403(b) including, but not limited to information regarding the participant's employment status, hardship withdrawals, and plan loans.

Acknowledgements and Signatures continued on next page..

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Acknowledgements and Signatures continued

Direct Rollover or Conversion

I have read the "Special Tax Notice for Plan Distributions" and I understand that I have the right to consider the decision of whether or

not to consent to a distribution and/or to elect a direct rollover for at least 30 days. I further understand that if I submit a completed distribution form before this 30 day period expires, I will have waived these rights and my distribution request will begin processing upon receipt. I met the following triggering events as specified in the Technical and Miscellaneous Revenue Act of 1988 (check all that apply):

I have attained age 59½ by the date of this request.

I am the surviving spouse beneficiary of the deceased annuitant and the Successor Fiduciary account is a Traditional IRA.

I have severed employment (including retirement) with the employer who purchased the contract.

Severance Date (MMDDYYYY)	Were you or will you be age 55 in the calendar year you severed employment?
		Yes		No

I certify that I am aware of the rules and requirements regarding 403(b) account transfers and exchanges, and have had the opportunity to consult with my personal tax Advisor regarding this transaction. I further acknowledge that I may need to request that my employer enter into an information sharing agreement or other necessary documentation with the Company named in Part 2 in order to maintain the tax-qualified status of my 403(b) account.

Owner NameOwner Phone Number

Owner Signature		Date (MMDDYYYY)
X

Consent of spouse is required for distributions from 403(b) plans that are subject to ERISA. If you are unsure if your plan is subject to ERISA (and consequently spousal consent requirements) check with your plan sponsor. (Usually your employer).

Generally:

403(b) plans sponsored by a governmental entity such as a public school or university are not subject to ERISA.

403(b) plans sponsored by a church or qualified church controlled organization are generally not subject to ERISA, however some exceptions may apply.

403(b) plans sponsored by a 501(c)(3) (non-profit) organization may be subject to ERISA depending on the design and operation of the plan.

!The spouse's signature must be witnessed by either the Plan Sponsor/Administrator or a Notary Public.

For governmental and ERISA plans, the requested transaction has been approved and acknowledged by; OR for 501(c) (3) non-ERISA plans, the Plan Sponsor represents that the participant had a termination of employment.

I acknowledge and approve the requested transaction.

For ERISA Plans, with the authority to act on behalf of the Plan, I certify that the participant's spouse

personally appeared before me with evidence to be the person whose name is named below and executed the foregoing document voluntarily. Plan Sponsor/Third Party Administrator Name

Plan Sponsor/Third Party Administrator Entity Name

Plan Sponsor/Third Party Administrator Signature

X

Spousal Consent (Required for 403(b) plans subject to ERISA)

!The spouse's signature must be witnessed by either the Plan Sponsor/Administrator or a Notary Public.

Owner's marital status: Single Married Widowed Divorced

I understand that, as the owner’s spouse, I have certain rights concerning his or her benefits, including the right to receive any death benefits unless I consent to another disposition. I hereby consent to the above requested withdrawal and I acknowledge that this consent will have the effect of waiving any and all rights concerning this withdrawal.

Spouse Name						Spouse Social Security Number
Spouse Signature						Date (MMDDYYYY)

X

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Part 6 Notarization

I certify that personally appeared before me with satisfactory evidence to be the person whose name is subscribed within the 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 executed the instrument.

Signature of Notary

Date (MMDDYYYY)

	Part 7	Letter of Acceptance and Surrender Request (Completed by a Corporate Officer of Company referenced
		in Part 2)

By signature of an authorized Officer below, the company named in Part 2 accepts assignment of the above-referenced policy for the purpose of complying with the client's intention of effecting either an IRA or 403(b) rollover of qualified funds, direct conversion of qualified funds to a Roth IRA, or a direct transfer of qualified funds.

For 403(b) Transfers

By signature below, I acknowledge that the Company named in Part 2 is (i) an approved investment provider for the 403(b) plan sponsored by the Plan Sponsor identified in Part 3 or (ii) has entered into an information sharing agreement with the named Plan Sponsor.

Corporate Officer Signature and Title

Date (MMDDYYYY)

X

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SPECIAL TAX NOTICE FOR PLAN DISTRIBUTIONS

Your Rollover Options

You are receiving this notice because all or a portion of a payment you are receiving from your 403(b) annuity or custodial account relating to your employer's 403(b) plan (the “Plan”) is eligible to be rolled over to an IRA or an employer plan. This notice is intended to help you decide whether to do such a rollover.

This notice describes the rollover rules that apply to payments from the Plan that are not from a designated Roth account (a type of account with special tax rules in some employer plans). If you also receive a payment from a designated Roth account in the Plan, you will be provided a different notice for that payment, and the Plan administrator or the payor will tell you the amount that is being paid from each account.

Rules that apply to most payments from a plan are described in the “General Information About Rollovers” section. Special rules that only apply in certain circumstances are described in the “Special Rules and Options” section.

General Information About Rollovers

How can a rollover affect my taxes?

You will be taxed on a payment from the Plan if you do not roll it over. If you are under age 591/2 and do not do a rollover, you will also have to pay a 10% additional income tax on early distributions (unless an exception applies). However, if you do a rollover, you will not have to pay tax until you receive payments later and the 10% additional income tax will not apply if those payments are made after you are age 591/2 (or if an exception applies).

Where may I roll over the payment?

You may roll over the payment to either an IRA (an individual retirement account or individual retirement annuity) or an employer plan (a tax-qualified plan, section 403(b) plan, or governmental section 457(b) plan) that will accept the rollover. The rules of the IRA or employer plan that holds the rollover will determine your investment options, fees, and rights to payment from the IRA or employer plan (for example, no spousal consent rules apply to IRAs and IRAs may not provide loans). Further, the amount rolled over will become subject to the tax rules that apply to the IRA or employer plan.

How do I do a rollover?

There are two ways to do a rollover. You can do either a direct rollover or a 60-day rollover.

If you do a direct rollover, the Plan will make the payment directly to your IRA or an employer plan. You should contact the IRA sponsor or the administrator of the employer plan for information on how to do a direct rollover.

If you do not do a direct rollover, you may still do a rollover by making a deposit into an IRA or eligible employer plan that will accept it. You will have 60 days after you receive the payment to make the deposit. If you do not do a direct rollover, the Plan is required to withhold 20% of the payment for federal income taxes (up to the amount of cash and property received other than employer stock). This means that, in order to roll over the entire payment in a 60-day rollover, you must use other funds to make up for the 20% withheld. If you do not roll over the entire amount of the payment, the portion not rolled over will be taxed and will be subject to the 10% additional income tax on early distributions if you are under age 591/2 (unless an exception applies).

How much may I roll over?

If you wish to do a rollover, you may roll over all or part of the amount eligible for rollover. Any payment from the Plan is eligible for rollover, except:

Certain payments spread over a period of at least 10 years or over your life or life expectancy (or the lives or joint life expectancy of you and your beneficiary)

Required minimum distributions after age 701/2; (or after death) Hardship distributions

ESOP dividends

Corrective distributions of contributions that exceed tax law limitations

Loans treated as deemed distributions (for example, loans in default due to missed payments before your employment ends) Cost of life insurance paid by the Plan

Contributions made under special automatic enrollment rules that are withdrawn pursuant to your request within 90 days of enrollment Amounts treated as distributed because of a prohibited allocation of S corporation stock under an ESOP (also, there will generally be adverse tax consequences if you roll over a distribution of S corporation stock to an IRA).

The Plan administrator or the payor can tell you what portion of a payment is eligible for rollover.

If I don't do a rollover, will I have to pay the 10% additional income tax on early distributions?

If you are under age 591/2, you will have to pay the 10% additional income tax on early distributions for any payment from the Plan (including amounts withheld for income tax) that you do not roll over, unless one of the exceptions listed below applies. This tax is in addition to the regular income tax on the payment not rolled over.

The 10% additional income tax does not apply to the following payments from the Plan:

Payments made after you separate from service if you will be at least age 55 in the year of the separation

Payments that start after you separate from service if paid at least annually in equal or close to equal amounts over your life or life expectancy (or the lives or joint life expectancy of you and your beneficiary)

Payments from a governmental defined benefit pension plan made after you separate from service if you are a public safety employee and you are at least age 50 in the year of the separation

Payments made due to disability

Payments after your death

Payments of ESOP dividends

Corrective distributions of contributions that exceed tax law limitations

Cost of life insurance paid by the Plan

Contributions made under special automatic enrollment rules that are withdrawn pursuant to your request within 90 days of enrollment

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Payments made directly to the government to satisfy a federal tax levy Payments made under a qualified domestic relations order (QDRO) Payments up to the amount of your deductible medical expenses

Certain payments made while you are on active duty if you were a member of a reserve component called to duty after September 11, 2001 for more than 179 days

Payments of certain automatic enrollment contributions requested to be withdrawn within 90 days of the first contribution.

If I do a rollover to an IRA, will the 10% additional income tax apply to early distributions from the IRA?

If you receive a payment from an IRA when you are under age 591/2, you will have to pay the 10% additional income tax on early distributions from the IRA, unless an exception applies. In general, the exceptions to the 10% additional income tax for early distributions from an IRA are the same as the exceptions listed above for early distributions from a plan. However, there are a few differences for payments from an IRA, including:

There is no exception for payments after separation from service that are made after age 55.

The exception for qualified domestic relations orders (QDROs) does not apply (although a special rule applies under which, as part of a divorce or separation agreement, a tax-free transfer may be made directly to an IRA of a spouse or former spouse).

The exception for payments made at least annually in equal or close to equal amounts over a specified period applies without regard to whether you have had a separation from service.

There are additional exceptions for (1) payments for qualified higher education expenses, (2) payments up to $10,000 used in a qualified first-time home purchase, and (3) payments after you have received unemployment compensation for 12 consecutive weeks (or would have been eligible to receive unemployment compensation but for self-employed status).

Will I owe State income taxes?

This notice does not describe any State or local income tax rules (including withholding rules).

Special Rules And Options

If your payment includes after-tax contributions

After-tax contributions included in a payment are not taxed. If a payment is only part of your benefit, an allocable portion of your after-tax contributions is generally included in the payment. If you have pre-1987 after-tax contributions maintained in a separate account, a special rule may apply to determine whether the after-tax contributions are included in a payment.

You may roll over to an IRA a payment that includes after-tax contributions through either a direct rollover or a 60-day rollover. You must keep track of the aggregate amount of the after-tax contributions in all of your IRAs (in order to determine your taxable income for later payments from the IRAs). If you do a direct rollover of only a portion of the amount paid from the Plan and a portion is paid to you, each of the payments will include an allocable portion of the after-tax contributions. If you do a 60-day rollover to an IRA of only a portion of the payment made to you, the after-tax contributions are treated as rolled over last. For example, assume you are receiving a complete distribution of your benefit which totals $12,000, of which $2,000 is after- tax contributions. In this case, if you roll over $10,000 to an IRA in a 60-day rollover, no amount is taxable because the $2,000 amount not rolled over is treated as being after-tax contributions.

You may roll over to an employer plan all of a payment that includes after-tax contributions, but only through a direct rollover (and only if the receiving plan separately accounts for after-tax contributions and is not a governmental section 457(b) plan). You can do a 60-day rollover to an employer plan of part of a payment that includes after-tax contributions, but only up to the amount of the payment that would be taxable if not rolled over.

If you miss the 60-day rollover deadline

Generally, the 60-day rollover deadline cannot be extended. However, the IRS has the limited authority to waive the deadline under certain extraordinary circumstances, such as when external events prevented you from completing the rollover by the 60-day rollover deadline. To apply for a waiver, you must file a private letter ruling request with the IRS. Private letter ruling requests require the payment of a nonrefundable user fee. For more information, see IRS Publication 590, Individual Retirement Arrangements (IRAs).

If you have an outstanding loan that is being offset

If you have an outstanding loan from the Plan, your Plan benefit may be offset by the amount of the loan, typically when your employment ends. The loan offset amount is treated as a distribution to you at the time of the offset and will be taxed (including the 10% additional income tax on early distributions, unless an exception applies) unless you do a 60-day rollover in the amount of the loan offset to an IRA or employer plan.

If you were born on or before January 1, 1936

If you were born on or before January 1, 1936 and receive a lump sum distribution that you do not roll over, special rules for calculating the amount of the tax on the payment might apply to you. For more information, see IRS Publication 575, Pension and Annuity Income.

If your payment is from a governmental section 457(b) plan

If the Plan is a governmental section 457(b) plan, the same rules described elsewhere in this notice generally apply, allowing you to roll over the payment to an IRA or an employer plan that accepts rollovers. One difference is that, if you do not do a rollover, you will not have to pay the 10% additional income tax on early distributions from the Plan even if you are under age 591/2 (unless the payment is from a separate account holding rollover contributions that were made to the Plan from a tax-qualified plan, a section 403(b) plan, or an IRA). However, if you do a rollover to an IRA or to an employer plan that is not a governmental section 457(b) plan, a later distribution made before age 591/2 will be subject to the 10% additional income tax on early distributions (unless an exception applies). Other differences are that you cannot do a rollover if the payment is due to an “unforeseeable emergency” and the special rules under “If your payment includes employer stock that you do not roll over” and “If you were born on or before January 1, 1936” do not apply.

If you are an eligible retired public safety officer and your pension payment is used to pay for health coverage or qualified long-term care insurance

If the Plan is a governmental plan, you retired as a public safety officer, and your retirement was by reason of disability or was after normal retirement age, you can exclude from your taxable income plan payments paid directly as premiums to an accident or health plan (or a qualified long-term care insurance contract) that your employer maintains for you, your spouse, or your dependents, up to a maximum of $3,000 annually. For this purpose, a public safety officer is a law enforcement officer, firefighter, chaplain, or member of a rescue squad or ambulance crew.

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If you roll over your payment to a Roth IRA

If you roll over the payment to a Roth IRA, a special rule applies under which the amount of the payment rolled over (reduced by any after-tax amounts) will be taxed. However, the 10% additional income tax on early distributions will not apply (unless you take the amount rolled over out of the Roth IRA within 5 years, counting from January 1 of the year of the rollover). For payments from the Plan during 2010 that are rolled over to a Roth IRA, the taxable amount can be spread over a 2-year period starting in 2011.

If you roll over the payment to a Roth IRA, later payments from the Roth IRA that are qualified distributions will not be taxed (including earnings after the rollover). A qualified distribution from a Roth IRA is a payment made after you are age 591/2 (or after your death or disability, or as a qualified first-time homebuyer distribution of up to $10,000) and after you have had a Roth IRA for at least 5 years. In applying this 5-year rule, you count from January 1 of the year for which your first contribution was made to a Roth IRA. Payments from the Roth IRA that are not qualified distributions will be taxed to the extent of earnings after the rollover, including the 10% additional income tax on early distributions (unless an exception applies). You do not have to take required minimum distributions from a Roth IRA during your lifetime. For more information, see IRS Publication 590, Individual Retirement Arrangements (IRAs).

You cannot roll over a payment from the Plan to a designated Roth account in an employer plan.

If you are not a plan participant

Payments after death of the participant. If you receive a distribution after the participant's death that you do not roll over, the distribution will generally be taxed in the same manner described elsewhere in this notice. However, the 10% additional income tax on early distributions does not apply, and the special rule described under the section “If you were born on or before January 1, 1936” applies only if the participant was born on or before January 1, 1936.

If you are a surviving spouse. If you receive a payment from the Plan as the surviving spouse of a deceased participant, you have the same rollover options that the participant would have had, as described elsewhere in this notice. In addition, if you choose to do a rollover to an IRA, you may treat the IRA as your own or as an inherited IRA.

An IRA you treat as your own is treated like any other IRA of yours, so that payments made to you before you are age 591/2 will be subject to the 10% additional income tax on early distributions (unless an exception applies) and required minimum distributions from your IRA do not have to start until after you are age 701/2.

If you treat the IRA as an inherited IRA, payments from the IRA will not be subject to the 10% additional income tax on early distributions. However, if the participant had started taking required minimum distributions, you will have to receive required minimum distributions from the inherited IRA. If the participant had not started taking required minimum distributions from the Plan, you will not have to start receiving required minimum distributions from the inherited IRA until the year the participant would have been age 701/2 .

If you are a surviving beneficiary other than a spouse. If you receive a payment from the Plan because of the participant's death and you are a designated beneficiary other than a surviving spouse, the only rollover option you have is to do a direct rollover to an inherited IRA. Payments from the inherited IRA will not be subject to the 10% additional income tax on early distributions. You will have to receive required minimum distributions from the inherited IRA.

Payments under a qualified domestic relations order. If you are the spouse or former spouse of the participant who receives a payment from the Plan under a qualified domestic relations order (QDRO), you generally have the same options the participant would have (for example, you may roll over the payment to your own IRA or an eligible employer plan that will accept it). Payments under the QDRO will not be subject to the 10% additional income tax on early distributions.

If you are a nonresident alien

If you are a nonresident alien and you do not do a direct rollover to a U.S. IRA or U.S. employer plan, instead of withholding 20%, the Plan is generally required to withhold 30% of the payment for federal income taxes. If the amount withheld exceeds the amount of tax you owe (as may happen if you do a 60-day rollover), you may request an income tax refund by filing Form 1040NR and attaching your Form 1042-S. See Form W-8BEN for claiming that you are entitled to a reduced rate of withholding under an income tax treaty. For more information, see also IRS Publication 519, U.S. Tax Guide for Aliens, and IRS Publication 515, Withholding of Tax on Nonresident Aliens and Foreign Entities.

Other special rules

If a payment is one in a series of payments for less than 10 years, your choice whether to make a direct rollover will apply to all later payments in the series (unless you make a different choice for later payments).

If your payments for the year are less than $200 (not including payments from a designated Roth account in the Plan), the Plan is not required to allow you to do a direct rollover and is not required to withhold for federal income taxes. However, you may do a 60-day rollover.

Unless you elect otherwise, a mandatory cashout of more than $1,000 (not including payments from a designated Roth account in the Plan) will be directly rolled over to an IRA chosen by the Plan administrator or the payor. A mandatory cashout is a payment from a plan to a participant made before age 62 (or normal retirement age, if later) and without consent, where the participant's benefit does not exceed $5,000 (not including any amounts held under the plan as a result of a prior rollover made to the plan).

You may have special rollover rights if you recently served in the U.S. Armed Forces. For more information, see IRS Publication 3, Armed Forces' Tax Guide.

For More Information

You may wish to consult with the Plan administrator or payor, or a professional tax advisor, before taking a payment from the Plan. Also, you can find more detailed information on the federal tax treatment of payments from employer plans in: IRS Publication 575, Pension and Annuity Income; IRS Publication 590, Individual Retirement Arrangements (IRAs); and IRS Publication 571, Tax-Sheltered Annuity Plans (403(b) Plans). These publications are available from a local IRS office, on the web at www.irs.gov , or by calling 1-800-TAX-FORM.

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