Polynous Growth Fund INDIVIDUAL RETIREMENT ACCOUNT (IRA) REQUEST FOR TRANSFER IMPORTANT: In compliance with the USA PATRIOT Act, Federal law requires all financial institutions (including mutual funds) to obtain, verify, and record information that identifies each person who opens an account. WHAT THIS MEANS FOR YOU: When you open an account, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask for additional identifying documents. The information is required for all owners, co-owners, or anyone who will be signing or transacting on behalf of a legal entity that will own the account. We will return your application if any of this information is missing. If we are unable to verify this information, your account may be closed and you will be subject to all applicable costs. If you have any questions regarding this application or how to invest, please call Shareholder Services at 1-800-528-8069. To transfer funds from an IRA with another financial institution, complete a New Account Agreement (unless the proceeds will purchase shares in an existing account) and this Request for Transfer Form. We will establish your IRA and send a letter of acceptance to the financial institution currently holding your IRA to complete the transfer. PART I: INVESTOR INFORMATION
(First, M.I., Last) (* Denotes Required Information)
Date of Birth* Social Security Number* State* Daytime Phone Evening Phone Zip Code* Owner's Name* Street Address (Physical Address)* Apartment # City* U.S. Citizen Resident Alien (Country) _____________________ PART II: INFORMATION ABOUT THE IRA YOU ARE TRANSFERRING
Name on Account City* Name of Contact State* Contact's Phone Number Zip Code* Firm Currently Holding Your IRA Address Account Number PLEASE ATTACH A STATEMENT FOR THE IRA YOU ARE TRANSFERRING A. Type of IRA (Check only one) Traditional IRA Rollover IRA SEP-IRA Roth Contribution IRA Roth Conversion IRA B. Investment Type (Check only one) Transfer of assets from another financial institution (Complete New Account Agreement). Transfer of assets from another financial institution to Roth Conversion IRA (Complete New Account Agreement and Withholding Instructions section of this form.) Transfer In Kind ­ Regarding your existing IRA, provide the:
Fund Name Account Number PART III:
Check One: TRANSFER INSTRUCTIONS This is a new account; a completed New Account Agreement is attached. Allocate my assets as listed below. The proceeds of this transfer will purchase shares into my existing account as listed below. Transfer Allocation List the fund(s) into which proceeds will be transferred. Using whole percentages, the total must add up to 100%. FUND CHOICE Polynous Growth Fund TOTAL PERCENTAGE % % PART IV: TRANSFER INSTRUCTIONS TO THE FINANCIAL INSTITUTION CURRENTLY HOLDING YOUR IRA
Liquidate immediately Liquidate at Maturity Date ________ / ________ / _________ Check All That Apply: Transfer entire balance Transfer only $ ______________ Transfer in kind NOTE: If you are transferring a Certificate of Deposit (CD), mail this form at least 14 days, but not more than 21 days before the maturity date. If you choose to wire-transfer your funds, contact Shareholder Services for instructions. PART V: WITHHOLDING INSTRUCTIONS FOR ROTH CONVERSION IRA When converting all or a portion of your IRA to a Roth Conversion IRA, the conversion amount is a taxable distribution. IRS regulations require the financial institution currently holding your IRA to withhold federal income tax from the amount you convert unless you do not want withholding to occur. The minimum withholding rate is 10%. Indicate your withholding election below: Withhold 10% Withhold - __________________%
Do Not Withhold Age 59½ or older PART VI: INVESTOR SIGNATURE To the Financial Institution currently holding my IRA: I certify that I have established an IRA with Unified Financial Securities, Inc. I agree to contact my present Custodian/Trustee that I am transferring from to determine if specific documentation or a signature guarantee is required. I understand that I am responsible for determining my eligibility for all transfers or direct rollovers. I agree to hold Unified Financial Securities, Inc. harmless against any and all situations arising from an ineligible transfer or direct rollover. I acknowledge that Unified Financial Securities, Inc. cannot provide legal advice and I agree to consult with my own tax professional for advice. X Investor' s Signature PART VII: SIGNATURE GUARANTEE (IF REQUIRED BY CURRENT FINANCIAL INSTITUTION) A signature guarantee is designed to protect the account from fraud. The following institutions are acceptable signature guarantors: Participants in good standing of the Securities Transfer Agents Medallion Program ("STAMP") Commercial banks which are members of the Federal Deposit Insurance Corporation ("FDIC") Trust Companies Firms which are members of a domestic stock exchange Eligible guarantor institutions qualifying under Rule 17Ad-15 of the Securities Exchange Act of 1934, as amended, that are authorized by charger to provide signature guarantees (e.g., credit unions, securities dealers and brokers, clearing agencies and national securities exchanges Foreign branches of any of the above.
¡ ¡ ¡ ¡ ¡ ¡ Note: The Transfer Agent cannot honor guarantees from notaries public, savings and loan associations, or saving banks. PART VIII: CUSTODIAN ACCEPTANCE ­ TO BE COMPLETED BY THE NEW CUSTODIAN Unified Financial Securities accepts appointment as Custodian and accepts the transfer described in this form. Please transfer all or part of the designated account(s) as instructed. Make the check payable to Polynous Growth Fund and mail to one of the addresses below. Third party checks are not acceptable. X Custodian' s Signature Title MAILING INSTRUCTIONS
Please send completed form to: Regular Mail Delivery Polynous Growth Fund P.O. Box 6110 Indianapolis, IN 46206-6110 Overnight Delivery Polynous Growth Fund 431 N. Pennsylvania Street Indianapolis, IN 46204 IRS Reporting. For IRS reporting purposes I am (check one): Less than age 59½ Date SIGNATURE GUARANTEE Date