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Get For Additional Beneficiaries, See Attached Form. - American Capital ...

D Address Date of Birth SSN SECTION TWO: TYPE OF CONTRIBUTION Select One: IR IR RR IRA DI IRA Rollover from Qualified Plan, TSA/403(b), or Governmental 457(b) - Commingled (Complete Rollover Certification) IP IRA Rollover from Qualified Plan, TSA/403(b), or Governmental 457(b) - Segregated (Complete Rollover Certification) IS Decedent IRA SEP/IRA Business Name: (Attach copy of employer s SEP document.) Employer s SEP.

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