IMPORTANT TO REVOKE THE ACCOUNT

Transcription

1 IRA CHECKLISTS 409 Silverside Rad, Suite 105 Wilmingtn, DE P: F: Please fllw the apprpriate checklists t ensure all dcuments are cmplete befre submitting them t The Bancrp. If yu are nt ready t clse the Accunt but wish t assert wnership f it and designate yur beneficiary(ies), cmplete Checklist 1. When yu are ready t clse the Accunt yu will be required t cmplete Checklist 2. If yu wish t clse the Accunt, cmplete Checklists 1 and 2. The clsure prcess cannt begin until all dcuments are received, all required sectins are cmplete, and yur identity has been verified. Missing r incmplete dcuments will delay prcessing f yur request. Hw t Submit Dcuments Please visit us at thebancrpbank.cm t securely submit yur dcuments nline. Yu may als 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: IMPORTANT TO REVOKE THE ACCOUNT, YOU MUST SEND THE COMPLETED AND NOTARIZED DOCUMENTS USING ONLY FIRST-CLASS MAIL TO THE ADDRESS INDICATED ABOVE, OR BY USING THE POSTAGE-PAID ENVELOPE INCLUDED IN YOUR WELCOME KIT, WITHIN THE TIMEFRAME DISCLOSED IN THE DISCLOSURE STATEMENT. Checklist 1 PART 1: IRA Owner/Beneficiary Infrmatin* PART 4: Beneficiary Designatin: Designate Primary and/r Cntingent Beneficiaries. PART 6: Adptin and Acknwledgment: Date and sign this sectin in the presence f a ntary public. PART 10: TIN Certificatin: Date and sign this sectin in the presence f a ntary public. PART 11: Ntary Acknwledgment: This sectin must be ntarized t ensure all signing parties executed the agreement willingly, under their wn pwer, and verified their identity in the presence f the ntary public. *If yu are a beneficiary asserting wnership ver a deceased IRA wner s accunt, skip PART 1A and cmplete PART 1B with yur infrmatin and enclse the death certificate and any ther required dcuments. If yu wish t clse the accunt, please select Inherited IRA distributin in PART 7 and prvide the IRA wner s name and Scial Security number. Nte: PARTS 2, 3, and 5 d nt require yur signature r additinal infrmatin t be prvided, but it is imprtant that yu review each t understand yur rights as the Safe Harbr accunt hlder. Nte: If submitting an nline clsure request, yu must re-enter the answers frm Checklist 2 int the crrespnding sectins. Checklist 2 PART 7: 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 8: 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 9: Payment Instructins: Review the ptins and select ne. The available 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.

2 THIS FORM MUST BE NOTARIZED. PARTS 6 AND 10 MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC. PART 1: IRA Owner/Beneficiary Infrmatin IRA Owner Beneficiary If yu are a beneficiary asserting wnership f a deceased IRA wner s accunt, skip PART 1A and cmplete PART 1B with yur infrmatin and enclse the death certificate and ther dcuments. PART 1A: IRA Owner Infrmatin IRA Owner s First Name: IRA Owner s MI: IRA Owner s Last Name: SAFE HARBOR IRA APPLICATION, ADOPTION 409 Silverside Rad, Suite 105 Wilmingtn, DE P: F: IRA Owner s SSN: IRA Owner s Date f Birth: Address: City: State: ZIP Cde: Hme Phne: Mbile Phne: Address: Accunt Type: Safe Harbr IRA PART 1B: Beneficiary Infrmatin First Name: MI: Last Name: SSN: Date f Birth: Address: City: State: Zip: Hme Phne: Mbile Phne: Address: PART 2: Investment The sle cntributins permitted t yur Safe Harbr IRA ( Accunt r Safe Harbr IRA ) are the direct rllver distributin(s) made by the plan spnsr r administratr f the eligible retirement plan in which yu had previusly participated (the Distributing Plan ). N ther cntributins are permitted. The cntributin(s) made by the Distributing Plan will be invested in an FDIC-insured mney market accunt maintained by The Bancrp Bank (the Bank Mney Market Accunt ) r such ther investment as determined by The Bancrp Bank t be a qualified investment under Department f Labr Regulatins a-2(c)(3)(i), (ii) and (iii). Yur Safe Harbr IRA is a limited purpse, nn-transactinal accunt held fr yur benefit. Yu are nt permitted t direct the investment f the Accunt ther than in the Bank Mney Market Accunt r ther qualified investment designated by The Bancrp Bank. As addressed in the Disclsure Statement, if yu cnclude that the Accunt is nt invested cnsistent with yur gals, yu may direct The Bancrp Bank t distribute yur Accunt, r transfer yur Accunt t anther eligible retirement plan r IRA maintained by anther IRA prvider. PART 3: Beneficiary Infrmatin The Department f Labr has determined that yur Safe Harbr IRA is nt cntrlled by any beneficiary designatin under the Distributing Plan and that The Bancrp Bank, as Trustee f yur Safe Harbr IRA established n yur behalf by the spnsr r administratr f the Distributing Plan, may establish a default beneficiary fr such IRA. The fllwing is The Bancrp Bank s default beneficiary designatin and it will be effective until yu make alternative beneficiary designatins as prvided belw: If n beneficiary designatin is effective at Grantr s death, then upn Trustee having been ntified f the death f the Grantr, and such fact is verified t Trustee s satisfactin, the remaining assets in the Accunt will be distributed ne hundred percent (100) t the spuse f the Grantr, r if there is n spuse surviving r if the Grantr was never married, distributin shall be t the executr r administratr f the Grantr s estate. SHTradIRA_AdptinAgreement_ (Part 4 appears n the next page)

3 SAFE HARBOR IRA APPLICATION, ADOPTION Page 2 f 6 PART 4: Beneficiary Designatin The fllwing individual(s) shall be my primary and/r cntingent beneficiary(ies). If neither primary nr cntingent is indicated, the individual will be deemed t be a primary beneficiary. If mre than ne primary beneficiary is designated and n distributin percentages are indicated, the beneficiaries will be deemed t wn equal shared percentages in the Accunt. Multiple cntingent beneficiaries with n share percentage indicated will als be deemed t share equally. If any primary r cntingent beneficiary dies befre me, the beneficiary s interest and the interest f the beneficiary s heirs shall terminate cmpletely, and the percentage share f any remaining beneficiary(ies) shall be increased n a pr rata basis. If n primary beneficiary(ies) survives me, the cntingent beneficiary(ies) shall acquire the designated share f my Accunt. Percentages must ttal 100. If a minr is being designated as a primary r cntingent beneficiary, it is recmmended that yu als cmplete the Designatin f Custdian fr Minr Beneficiaries Under the Unifrm Transfers t Minrs Act (UTMA) sectin in PART 4B. If yu are dmiciled in a cmmunity r marital prperty state and are naming as a primary beneficiary smene ther than yur spuse, please see the spusal cnsent sectin in PART 4B. I, my successrs and assigns, agree t indemnify and hld harmless The Bancrp Bank and its affiliates and any directrs, fficers, emplyees r agents f these entities frm and against any and all claims, liabilities, damages, actins, charges, csts, lsses and expenses (including reasnable attrneys fees) arising ut f r resulting frm the transfer r payment upn my death f the balance in this Accunt t the beneficiary(ies) listed in this Adptin Agreement. PART 4A: Primary Beneficiary Designatin(s) 1. Beneficiary Name and Address: Relatinship: SSN r Federal Tax Date f Birth: 2. Beneficiary Name and Address: Relatinship: SSN r Federal Tax Date f Birth: 3. Beneficiary Name and Address: Relatinship: SSN r Federal Tax Date f Birth: 4. Beneficiary Name and Address: Relatinship: SSN r Federal Tax Date f Birth: Ttal: 100 PART 4B: Cntingent Beneficiary Designatin(s) 1. Beneficiary Name and Address: Relatinship: SSN r Federal Tax Date f Birth: 2. Beneficiary Name and Address: Relatinship: SSN r Federal Tax Date f Birth: Ttal: 100 *If designating additinal beneficiaries, print extra cpies f this page.* SHTradIRA_AdptinAgreement_ (Part 4B cntinues n the next page)

4 SAFE HARBOR IRA APPLICATION, ADOPTION Page 3 f 6 PART 4B: Cntingent Beneficiary Designatin(s) (cntinued frm previus page) Designatin Of Custdian Fr Minr Beneficiaries Under The Unifrm Transfers T Minrs Act (UTMA) If a minr beneficiary is designated, I designate as Custdian fr such minr beneficiary under the Unifrm Transfers t Minrs Act (UTMA) f the State f my dmicile. If the Custdian is unable r unwilling t serve fr any reasn, I designate as successr Custdian. If n Custdian is named, r if the named Custdian(s) are unable r unwilling t serve fr any reasn, I designate the executr r administratr f my will as Custdian fr my minr beneficiary. If n Custdian is named r acting under the freging, the guardian f such minr beneficiary, whether appinted under a will r by curt, shall becme successr Custdian. Signature f Accunt Custdian, if applicable: Date: Spusal cnsent: (fr use in cmmunity r marital prperty states) I agree t my spuse naming a primary beneficiary ther than me. I transfer (transmute) any cmmunity prperty interest I have in this IRA int the separate prperty f my spuse. I agree t seek the advice f a legal r tax prfessinal, as needed. Signature f Spuse: Date: PART 5: Trustee Infrmatin; Revcatin Name and Address f The Bancrp Bank: The Bancrp Bank 409 Silverside Rad, Suite 105 Wilmingtn, DE Attentin: Safe Harbr IRA Revcatin This Safe Harbr IRA may be revked within seven (7) days f the date f its establishment ( Opening Date ) r ten (10) days frm the date The Bancrp Bank mailed the riginal Welcme Kit t yu, whichever is later. In rder t exercise yur right f revcatin, yu must prvide us timely written ntice f yur electin t revke. Yu must cmplete PARTS 1, 10 and 11 f this Adptin Agreement and prvide us with yur cmpleted, signed and ntarized cpy f it t be mailed by first-class mail t the name and address f The Bancrp Bank set frth abve. Delivery by r facsimile will nt be accepted. Because the Accunt was established by the Distributing Plan n yur behalf, we must cnfirm yur identity befre we send yu a check fr the remaining balance r therwise take directin frm yu. This prcess satisfies ur legal requirements under the USA PATRIOT Act and the Bank Secrecy Act, which mandates that we are able t cnfirm the identity f ur custmers. See the Disclsure Statement fr mre infrmatin, including a descriptin f the requirement t cmply with the USA PATRIOT Act and the rules f the Bancrp Custmer Identificatin Prgram (CIP). If yu chse t revke this Safe Harbr IRA, skip ahead t PARTS 10 and 11. PART 6: Adptin and Acknwledgement This Adptin Agreement applies t a Safe Harbr IRA established n my behalf by the fiduciary f my frmer emplyer s retirement plan pursuant t Sectin 657(c) f the Ecnmic Grwth and Tax Relief Recnciliatin Act f 2001 (EGTRRA). By signing belw, I acknwledge receipt f the Safe Harbr IRA Applicatin, Adptin Agreement, and Distributin Frm, the Autmatic Rllver Traditinal Individual Retirement Trust Accunt Agreement (Frm 5305), the Disclsure Statement, and agree t be bund by their respective terms as well as the terms f such ther agreements and disclsures as may apply, as amended by The Bancrp Bank frm time t time. I agree t seek the advice f a legal r tax prfessinal, as needed. The Bancrp Bank has nt prvided me with any legal r tax advice, and I assume full respnsibility fr this transactin. I will nt hld The Bancrp Bank liable fr any adverse cnsequences that may result frm this transactin. I agree that the infrmatin prvided by me n this frm is true and crrect. Signature f IRA Owner/Beneficiary: Date: Upn acknwledging receipt f the Adptin Agreement, the Autmatic Rllver Traditinal Individual Retirement Trust Accunt Agreement (Frm 5305), the Disclsure Statement, and agreeing t be bund by their respective terms, yu have the right t request a distributin f yur funds r t rll ver yur funds directly t a qualified plan (a 401(k) r IRA, fr example). If yu wish t take a distributin r rll ver yur funds, cntinue t PART 7. If yu nly wish t assert wnership ver the Accunt and leave the funds in the Accunt, skip ahead t PARTS 10 and 11. SHTradIRA_AdptinAgreement_ (Part 7 appears n the next page)

5 SAFE HARBOR IRA APPLICATION, ADOPTION Page 4 f 6 PART 7: Type f Distributin Please select a type f distributin by checking nly ne bx belw. Cnsult yur tax advisr fr infrmatin abut pssible tax penalties. Exceptins must be filed n IRS Frm Traditinal 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. 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 Frm 5329 (available at and file it with yur tax return. D nt send it t The Bancrp 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 9. Inherited IRA distributin: The 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 1B. If this happens, the accunt clsure may be delayed. IRA wner name: IRA wner SSN: Other, please explain This ptin shuld be chsen fr thse claiming disability r anther specific reasn nt included as an ptin abve. PART 8: 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. 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.) SHTradIRA_AdptinAgreement_ (Part 8 cntinues n the next page)

6 PART 8: Mandatry Tax Withhlding Requirements (cntinued frm previus page) 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 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. State law is subject t change, which may affect the accuracy f this table. SAFE HARBOR IRA APPLICATION, ADOPTION Page 5 f 6 PART 9: 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 8 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 Article 8 f 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 Article 8 f 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 8 abve. Balance f accunt. Receiving financial institutin infrmatin: Type f accunt: Checking Savings Name f receiving financial institutin: Accunt Number: Accunt Name: (must be in same name as IRA Owner/Beneficiary) City: State: Zip: Phne: ABA Ruting Number: SHTradIRA_AdptinAgreement_ (Part 10 appears n the next page)

7 SAFE HARBOR IRA APPLICATION, ADOPTION Page 6 f 6 PART 10: TIN Certificatin 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 penalty 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. I have read and understand the abve certificatin, agreements, authrizatins and indemnificatins. By signing this applicatin, I agree t be bund by the certificatin, agreements, authrizatins and indemnificatins, as well as the terms and cnditins f the Accunt. 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: PART 11: Ntary Acknwledgement (t be cmpleted by Ntary Public) STATE OF ) ) SS: COUNTY OF ) On this, the day f, 20, befre me, the undersigned Ntary Public, persnally appeared, knwn t me (r satisfactrily prven) t be the persn whse name is subscribed t this dcument, and acknwledged that said persn executed the same fr the purpse described within. In witness wheref, I heret set my hand and fficial seal. By: Ntary Public My Cmmissin Expires: SEAL: SHTradIRA_AdptinAgreement_121517

8 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