$35.00 per account Opening Date or ten (10) days from the date Bank mails your original Welcome Kit, whichever is later.)

Transcription

1 In rder t prcess yur request t clse yur Safe Harbr Traditinal r Rth Individual Retirement Accunt (IRA), please cmplete the enclsed IRA Distributin Request frm. Yu may return the dcument(s) in the enclsed pstagepaid envelpe, r fax them t us at The clsure prcess will begin upn receipt f all cmpleted required dcumentatin. Please nte that the distributin f funds frm yur IRA will be reprted t the Internal Revenue Service (IRS) n Frm 1099-R. In accrdance with IRS regulatins, yu may be required t pay federal and state taxes and/r a penalty n withdrawn funds. Fr details abut any taxes r penalties, please cntact yur tax advisr r the IRS directly. Belw is a list f the available distributin ptins, i.e., disbursement methds, and the related fees. Activity Fee Maintenance Fee (Fee assessed when the first depsit is made t the accunt. This Fee will be reimbursed if yu revke the Safe Harbr IRA within seven (7) days f the $35.00 per accunt Opening Date r ten (10) days frm the date Bank mails yur riginal Welcme Kit, whichever is later.) Annual Fee (Fee assessed annually t maintain the Safe Harbr IRA accunt.)this is charged $35.00 per year t yur accunt n the anniversary f the accunt pening date. Accunt Clsing Fee (Fee assessed t clse the Safe Harbr IRA. This Fee will nt be charged if yu $25.00 per accunt revke the Safe Harbr IRA within seven (7) days f the Opening Date r ten (10) days frm the date Bank mails yur riginal Welcme Kit, whichever is later.) Legal Prcessing Fee Lesser f $ r the (fr example, prcessing subpenas, garnishments, levies) maximum permitted by law per legal request received This will appear in yur transactin histry as LGL PROCESSING FEE Fees Related t Disbursement Methds (in additin t Accunt Clsing Fee, if any): Check made payable t accunt hlder N Fee Funds Transfer Fee Fr electrnic funds transfer (ACH) t anther financial institutin $5.00 per transactin This will appear in yur transactin histry as FUNDS TRANSFER FEE Treasurer s Check Fee Treasurer s check t anther financial institutin (csts include transfer $12.00 per check paperwrk, if required by receiving institutin) This will appear in yur transactin histry as TREASURERS CHECK Expedited Delivery Fee (vernight delivery) $50.00 per delivery This will appear in yur transactin histry as EXPEDITED DELIVERY Fr additinal infrmatin and instructins, please see the enclsed dcuments: Checklist f Dcuments t Be Returned IRA Distributin Request frm Substitute Frm W-4P Withhlding Certificate fr IRA Distributins If yu have any questins please cntact Custmer Care at

2 Checklist f Dcuments t Be Returned The clsure prcess cannt begin until all dcuments are received and all required sectins are cmplete. Please fllw the checklist t ensure efficient prcessing f yur request. Missing r incmplete dcuments will delay prcessing. If yu already submitted a cmpleted and ntarized Safe Harbr IRA Applicatin and Adptin Agreement, please cmplete nly the IRA Distributin Request frm. Hw t Submit Dcuments Submit yur dcuments by mail, using the pstage-paid envelpe included in yur Welcme Kit r yur wn envelpe, r by fax, t: The Bancrp Bank ATTN: Safe Harbr IRA 409 Silverside Rad Suite 105 Wilmingtn, DE Fax: IRA Distributin Request Frm: Part 1: IRA Owner/Beneficiary Infrmatin*: Cmplete this sectin in full. Part 2: Type f Distributin: Review the ptins and select the ne that applies t yu. If yu are unsure which ptin applies t yu, please seek the advice f a tax specialist. Part 3: Mandatry Tax Withhlding Requirements: Review the ptins. If yu are unsure which if any ptin applies t yu, please seek the advice f a tax specialist. Part 4: Payment Instructins: Review the ptins and select ne. The available payment ptins are: One-Time Check Payment: Use this ptin t initiate a rllver r transfer t anther IRA trustee/ custdian, r t request that a check be sent t yu. Please cnfirm with the receiving IRA trustee/ custdian whether it requires dcumentatin t accmpany the check. One-Time ACH Payment: Prvide infrmatin abut the receiving financial institutin r IRA trustee/ custdian. Part 5: Signature: Please read, sign, and date the frm. *If yu are a beneficiary asserting wnership ver a deceased IRA wner s accunt, please cmplete Part 1 with yur infrmatin and enclse the death certificate and any ther required dcuments, select Inherited IRA distributin in Part 2, and prvide the IRA wner s name and Scial Security number.

3 IRA DISTRIBUTION REQUEST 409 Silverside Rad, Suite 105 Wilmingtn, DE P: F: Cmplete this frm when requesting a distributin frm yur Traditinal r Rth Individual Retirement Accunt (IRA). T help the gvernment fight the funding f terrrism and mney laundering activities, federal law requires all financial institutins t btain, verify and recrd infrmatin that identifies each custmer wh pens an accunt. When yur IRA was transferred t us, yu became a new custmer f The Bancrp. As part f the distributin prcess, we will verify yur name, address, date f birth and ther infrmatin that will allw us t identify yu. Yu must cmplete and return the entire IRA Distributin Request frm and include all apprpriate dcumentatin as utlined in the Checklist f Dcuments t be Returned. Prcessing f yur request will begin when all cmpleted dcuments have been received. PART 1: IRA Owner/Beneficiary Infrmatin IRA Owner Beneficiary First Name: MI: Last Name: SSN: DOB: Address: City: State: Zip Cde: Hme Phne: Mbile Phne: PART 2: Type f Distributin Please select the apprpriate accunt type as either Traditinal IRA OR Rth IRA and then check nly ne bx belw. Cnsult yur tax advisr fr infrmatin abut pssible tax penalties. Exceptins must be filed n IRS Frm Traditinal IRA ROTH IRA Nrmal distributin: I am age 59½ r lder. Yu are eligible t begin taking distributins at age 59½, even if yu cntinue wrking. Yu are still required t pay taxes n the amunt withdrawn. Fr ROTH distributins, please review any tax cnsequences with yur tax advisr. Early (premature) distributin: I am under age 59½. Distributins befre age 59½ are subject t rdinary incme tax and may als be subject t a 10% federal penalty tax, unless yu meet an IRS exceptin. IRS exceptins may include: higher educatin expenses, qualified first hme purchase and substantially equal peridic payments (SEPP). A full list f exceptins is available n the instructin frm fr IRS Frm T claim an exceptin frm the premature distributin penalty, yu must cmplete IRS 5329 (available at and file it with yur tax return. D nt send it t the Bank fr prcessing. Rllver t a qualified plan: I want t rll ver my IRA directly t a qualified plan (a 401(k) r IRA, fr example). Yu cannt rll ver after-tax amunts frm yur IRA. We cannt certify whether yur IRA cntributins were pre-tax r after-tax; yu will need t prvide this certificatin. Yu must prvide the apprpriate name and address in the Receiving IRA Trustee/Custdian sectin in PART 4. Inherited IRA distributin: The riginal IRA wner has died, and I am the beneficiary. Please prvide death certificate and ther supprting dcuments. If additinal dcuments are needed, a representative will cntact yu using the infrmatin yu prvide in PART 1. If this happens, the accunt clsure may be delayed. IRA Owner Name: IRA Owner SSN: Other, please explain This ptin shuld be chsen fr thse claiming disability r anther specific reasn nt included as an ptin abve. FOR BANK USE ONLY Accunt Number: SHIRA_Distributin Frm_ REQ RITM

4 IRA Distributin Request Page 2 f 3 PART 3: Mandatry Tax Withhlding Requirements We encurage yu t cnsult with yur accuntant r tax advisr regarding IRA distributins. Yu may be subject t tax penalties under the estimated mandatry tax payment rules utlined in the table belw if yur payments f estimated tax and withhlding are nt accurate as prvided in this example: Distributin requested = $10,000; Taxes withheld = $1,000 (10%); Payment = $9,000 Nte: Any federal and applicable state taxes withheld will be deducted frm the ttal requested distributin amunt. If the distributin is frm a Rth IRA, it may be exempt frm state tax. Cnsult with yur accuntant r tax advisr t btain the mst up-t-date infrmatin n yur state s requirements. Federal Taxes Nte: IRS regulatins require that at least 10% federal incme tax be withheld frm a distributin. D nt withhld federal incme tax frm my IRA distributin. Withhld federal incme tax f % (at least 10%) frm my IRA distributin. State Taxes Nte: If n state tax withhlding electin is indicated, IRS regulatins require that the table shwn belw be fllwed. If yu reside in ne f the states that has mandatry withhlding, thse funds will be withheld frm the distributin. D nt withhld state incme tax frm my IRA distributin. Withhld state incme tax f % frm my IRA distributin. (Only applies if state incme tax is applicable. Please cnsult a tax advisr r the IRS fr guidance.) If yu live in: AR, GA, IA, KS, MA, ME, OK, VT CA, DE, OR, NC AL, FL, HI, NH, NV, SD, TN, TX, WA Residents f all ther states and the District f Clumbia State law is subject t change, which may affect the accuracy f this table. Yur ptins fr state tax withhlding are: Mandatry Mandatry nly if yu elect federal tax withhlding Prhibited Fr states nt referenced in the table, please cnsult with yur tax advisr as we DO NOT ffer a state withhlding ptin. SHIRA_Distributin Frm_ REQ RITM (Part 4 appears n the next page)

5 IRA Distributin Request Page 3 f 3 PART 4: Payment Instructins Please cmplete nly ne sectin belw. A check payable t the accunt hlder will be autmatically sent if n ther ptin is selected. ONE-TIME CHECK PAYMENT Distributin amunt: Nte: Tax withhlding electins may reduce the ttal amunt received. See Part 3 abve. Balance f accunt. Delivery methd: Standard delivery Overnight delivery* ($50.00 Expedited Delivery Fee and $12.00 Treasurer s Check Fee apply) Mailing instructins: Send t my address listed abve Send t receiving IRA Trustee/Custdian** ($12.00 Treasurer s Check Fee may apply) Name f receiving IRA Trustee/Custdian: Name f IRA wner: Address: City: State: Zip: * See the Disclsure Statement fr infrmatin abut this fee. Overnight delivery nt available t a P.O. Bx address. ** Attach cmpleted Transfer f Assets frm if required by receiving IRA trustee/custdian. $12.00 Treasurer s Check Fee applies. See the Disclsure Statement fr infrmatin abut this fee. ONE-TIME ACH PAYMENT Electrnic Transfer t Nn-Retirement Accunts nly ($5.00 Funds Transfer Fee applies) Distributin amunt: Nte: Tax withhlding electins may reduce the ttal amunt received. See Part 3 abve. Balance f accunt. Receiving financial institutin infrmatin: Type f accunt: Checking Savings Name f receiving financial institutin: Accunt Number: Accunt Name: ABA Ruting Number: (must be in same name as IRA Owner/Beneficiary) City: State: Zip: Phne: PART 5: TIN Certificatin and Authrizatin Signature Required I certify that, t the best f my knwledge, the infrmatin prvided n this frm is true and crrect and may be relied n by the Trustee/ Custdian. I understand that this transactin may be subject t fees, taxes and/r penalties. Due t the imprtant tax cnsequences f this transactin, I agree t seek the advice f a legal r tax prfessinal, as needed. The Trustee/Custdian has nt prvided me with any legal r tax advice, and I assume full respnsibility fr this transactin. I will nt hld the Trustee/Custdian liable fr any adverse cnsequences that may result frm this transactin. I understand that my IRA was transferred t The Bancrp Bank frm a previus plan spnsr. In rder fr The Bancrp Bank t prcess my distributin request, I authrize The Bancrp Bank t rder cnsumer reprts abut me frm cnsumer reprting agencies and instruct any persn r cnsumer reprting agency t cmpile and furnish any infrmatin it may have r btain abut me in respnse t such inquiries. Under penalties f perjury, I certify that: (1) the number shwn n this frm is my crrect Taxpayer Identificatin Number (TIN) (r I am waiting fr a number t be issued t me); (2) I am nt subject t backup withhlding, because (a) I am exempt frm backup withhlding under Internal Revenue Service (IRS) regulatins, r (b) I have nt been ntified by the IRS that I am subject t backup withhlding as a result f failure t reprt all interest r dividends, r (c) the IRS has ntified me that I am n lnger subject t backup withhlding; (3) I am a U.S. citizen (r a U.S. resident alien); and (4) I am exempt frm Freign Accunt Tax Cmpliance Act (FATCA) reprting. CERTIFICATION INSTRUCTION: If yu have been ntified by the IRS that yu are currently subject t backup withhlding because f underreprting interest r dividends n yur tax return, yu must crss ut Item 2, abve. THE INTERNAL REVENUE SERVICE DOES NOT REQUIRE YOUR CONSENT TO ANY PROVISION OF THIS DOCUMENT OTHER THAN THE CERTIFICATION REQUIRED TO AVOID BACKUP WITHHOLDING. Signature f IRA Owner/Beneficiary: Date: (mm/dd/yyyy) SHIRA_Distributin Frm_ REQ RITM

6 SUBSTITUTE FORM W-4P Department f the Treasury Internal Revenue Service Withhlding Certificate fr IRA Distributins OMB N Purpse The Withhlding Electin r Change f Electin sectin n this frm is fr U.S. citizens, resident aliens, r their estates wh are recipients f IRA distributins. Yu may use this frm t chse (a) nt t have any incme tax withheld frm the IRA distributin (except fr IRA distributins t U.S. citizens delivered utside the United States r its pssessins) r (b) t have an additinal amunt f tax withheld. Yur previusly filed withhlding electin will remain in effect if yu d nt cmplete the Withhlding Electin r Change f Electin sectin n this frm. Sign this frm The withhlding electin r change made n this frm is nt valid unless yu sign this frm. Sectin references are t the Internal Revenue Cde. Other Incme If yu have a large amunt f incme frm ther surces nt subject t withhlding (such as interest, dividends, r capital gains), cnsider making estimated tax payments using Frm 1040-ES, Estimated Tax fr Individuals. Call TAX-FORM ( ) t get Frm 1040-ES and Pub. 505, Tax Withhlding and Estimated Tax. Yu can als get frms and publicatins frm the IRS website at IRA Distributins 10% withhlding. Yur payer must withhld at a flat 10% rate frm yur IRA distributins unless yu chse nt t have incme tax withheld. Yu can chse nt t have incme tax withheld frm yur distributin by checking the first bx in the Withhlding Electin r Change f Electin sectin n this frm. Generally, yur chice nt t have incme tax withheld will apply t any later distributin frm the same IRA. Yu may specify an additinal amunt t be withheld by checking the secnd bx and indicating hw much yu want withheld. Cautin: If yu submit this frm withut yur crrect TIN, the payer cannt hnr yur request nt t have incme tax withheld and must withhld 10% f the IRA distributin fr federal incme tax. Chsing Nt t Have Incme Tax Withheld Yu (r in the event f death, yur beneficiary r estate) can chse nt t have incme tax withheld frm yur IRA distributins by checking the first bx in the Withhlding Electin r Change f Electin sectin n this frm. Fr an estate, the electin t have n incme tax withheld may be made by the executr r persnal representative f the decedent. Enter the estate s EIN in the area reserved fr Scial Security Number n this frm. Cautin: There are penalties fr nt paying enugh federal incme tax during the year, either thrugh withhlding r estimated tax payments. New retirees, especially, shuld see Pub It explains yur estimated tax requirements and describes penalties in detail. Yu may be able t avid quarterly estimated tax payments by having enugh tax withheld frm yur IRA distributins using the Withhlding Electin r Change f Electin sectin n this frm. Changing Yur N Withhlding Chice If yu previusly chse nt t have incme tax withheld and yu nw want withhlding, check the secnd bx in the Withhlding Electin r Change f Electin sectin n this frm. Payments t Freign Persns and Payments Outside the United States Unless yu are a nnresident alien, withhlding is required n any IRA distributins that are delivered t yu utside the United States r its pssessins. Yu cannt chse nt t have incme tax withheld. See Pub. 505 fr additinal details. In the absence f a tax treaty exemptin, nnresident aliens, nnresident alien beneficiaries, and freign estates generally are subject t a 30% withhlding tax under sectin 1441 n an IRA distributin. Hwever, mst tax treaties prvide that IRA distributins are exempt frm withhlding and tax. See Pub. 515, Withhlding f Tax n Nnresident Aliens and Freign Entities, and Pub. 519, U.S. Tax Guide fr Aliens, fr details. A freign persn shuld submit Frm W-8BEN, Certificate f Freign Status f Beneficial Owner fr United States Tax Withhlding, t the payer befre receiving any payments. The Frm W-8BEN must cntain the freign persn s TIN. Statement f Federal Incme Tax Withheld frm Yur IRA By January 31 f next year, yur payer will furnish a statement t yu n Frm 1099-R, Distributins Frm Pensins, Annuities, Retirement r Prfit-Sharing Plans, IRAs, Insurance Cntracts, etc., shwing the ttal amunt f yur IRA distributin and the ttal federal incme tax withheld during the year. If yu are a freign persn wh has prvided yur payer with Frm W-8BEN, yur payer instead will furnish a statement t yu n Frm 1042-S, Freign Persn s U.S. Surce Incme Subject t Withhlding, by March 15 f next year. Privacy Act and Paperwrk Reductin Act Ntice We ask fr the infrmatin n this frm t carry ut the Internal Revenue laws f the United States. Yu are required t prvide this infrmatin nly if yu want t (a) request additinal federal incme tax withhlding frm yur IRA distributin, (b) chse nt t have federal incme tax withheld, when permitted, r (c) change r revke a previus withhlding electin. T d any f the afrementined, yu are required by sectins 3405(e) and 6109 and their regulatins t prvide the infrmatin requested n this frm. Failure t prvide this infrmatin may result in inaccurate withhlding n yur payment(s). Rutine uses f this infrmatin include giving it t the Department f Justice fr civil and criminal litigatin, and t cities, states, the District f Clumbia, and U.S. cmmnwealths and pssessins fr use in administering their tax laws. We may als disclse this infrmatin t ther cuntries under a tax treaty, t federal and state agencies t enfrce federal nntax criminal laws, r t federal law enfrcement and intelligence agencies t cmbat terrrism. Yu are nt required t prvide the infrmatin requested n a frm that is subject t the Paperwrk Reductin Act unless the frm displays a valid OMB cntrl number. Bks r recrds relating t a frm r its instructins must be retained as lng as their cntents may becme material in the administratin f any Internal Revenue law. Generally, tax returns and return infrmatin are cnfidential, as required by sectin W-4PS 01/2010