Traditional, SEP or SIMPLE IRA Distribution Form

Transcription

1 ACCOUNT INFORMATION Your Name: Account Number: Type of IRA: [ ] Traditional IRA [ ] SEP IRA [ ] SIMPLE IRA Street Address: City: State: Zip Code: Telephone Number: Social Security Number: Date of Birth: Is this a death distribution? [ ] Yes [ ] No If YES, name of deceased IRA Owner: REASON FOR DISTRIBUTION 1. [ ] Early (premature) distribution (Account Holder is under age 59 ½ and no known exception applies). This reason applies to a distribution due to medical expenses, health insurance premiums, higher education expenses, first time home buyer expenses, qualified reservist distributions or modified substantially equal payments. 2. [ ] Early (premature) distribution. Distribution due to IRS levy exception applies, substantially equal payments, or Roth IRA conversions if Account Holder is under age 59 ½. 3. [ ] Permanent disability (if you are disabled within the meaning of section 72(m)(7) of the Internal Revenue Code). 4. [ ] Death (if you are a beneficiary of this account and can furnish a certified copy of the Death Certificate). 5. [ ] Normal distribution (if you are the Account Holder and age 59 ½ or older). 6. [ ] Removal of excess/nondeductible contribution plus earnings before tax filing deadline. In which tax year was the contribution made? Is the contribution plus earnings being removed in the same year? [ ] Yes [ ] No 7. [ ] Removal of excess contribution (principal only) after tax filing deadline. 8. [ ] Distribution from a SIMPLE IRA. Date employee first participated: 9. [ ] Transfer due to divorce or legal separation; qualified charitable distribution transfer; and qualified HSA funding distribution. Transfer payable to: 10. [ ] Conversion to a Roth IRA. 11. [ ] Recharacterization to a Roth IRA. Regular contribution of $ Earnings of $ For tax year: 12. [ ] IRA paid directly to trustee of employer s plan. Payable to: 13. [ ] Other (specify reason not listed above): FINANCIAL INFORMATION This distribution is a: [ ] Distribution of entire account balance [ ] Partial distribution [ ] In-kind distribution of asset: Asset name: Amount Requested: $ Fed Income Tax Withheld: $ Net Amount Distributed: $ Value of Asset Distributed: $ Page 1 of 3

2 METHOD OF DISTRIBUTION WITHHOLDING ELECTION Until I give written instructions to the contrary, I direct to distribute the amount requested as follows: Date to commence: Frequency: [ ] One Time [ ] Monthly [ ] Quarterly [ ] Semi-Annually [ ] Annually [ ] Check Send check to: [ ] Home Address [ ] Wire [ ] Different Address: [ ] ACH For Wires or ACH: Name of Bank: Account Name: Bank ABA/Routing Number: Account Number: Choose either Option 1 or 2. Complete for any kind of distribution, except reason #7, 9, 11 and 12 above. Option 1. [ ] Withhold federal income tax at the rate of % (not less than 10%) plus an additional amount of $ from the amount withdrawn. Option 2. [ ] Effective, I elect not to have federal income tax withheld. (Must have US residence address on file) I understand that I am still liable for the payment of federal income tax on the taxable amount. I also understand that I may be subject to tax penalties under the estimated tax payment rules, if my payments of estimated tax and withholding, if any, are not adequate. PAYMENT OF FEES (ALL FEES ARE DUE AT TIME OF DISTRIBUTION) Payment of fees associated with processing of the distribution shall be paid: [ ] From Account [ ] Credit Card Authorization Form attached Note: There are no applicable fees for required minimum distributions by check. Page 2 of 3

3 AUTHORIZATION I certify that I am the proper party to receive payment(s) from this IRA, and that all information provided by me is true and accurate. I acknowledge that I have read the Notice of Withholding below and have completed the Withholding Election above. I further certify that no tax advice has been given to me by or the Custodian, that distributions (except certain transfers) are reported to the IRS, and that all decisions regarding this withdrawal are my own. I expressly assume the responsibility for any adverse consequences which may arise from this withdrawal and I agree that and the Custodian shall in no way be responsible for those consequences. Account Holder s Signature: Date: NOTICE OF WITHHOLDING ON DISTRIBUTIONS FROM IRAs The distributions you receive from your individual retirement account established at this institution are subject to federal income tax withholding unless you elect not to have withholding apply. You may elect not to have withholding apply to your distribution payments by completing the Withholding Election section above. If you do not complete the Withholding Election section by the date your distribution is scheduled to begin, federal income tax will be withheld from the amount withdrawn at a rate of 10%. If you elect not to have withholding apply to your distribution payments, or if you do not have enough federal income tax withheld from your distribution, you may be responsible for payment of estimated tax. You may incur penalties under the estimated tax rules if your withholding and estimated tax payments are not sufficient. Page 3 of 3

4 A. ACCOUNT HOLDER INFORMATION Account Holder s Name: Roth IRA Rollover Form Account Number: NewAccounts@QuestIRA.com Address: City: State: Zip Code: Telephone Number: Social Security Number: B. FORMER CUSTODIAN OR EMPLOYER PLAN INFORMATION Name of Former Custodian or Employer Plan: Former Custodian or Employer Plan Account Number: C. FORM OF ROLLOVER This Rollover/Direct Rollover is a: Current statement is attached: [ ] Yes D. ASSET DESCRIPTION Asset: [ ] COMPLETE DISTRIBUTION/ROLLOVER [ ] PARTIAL DISTRIBUTION/ROLLOVER Please attach your most recent statement from your former custodian or employer plan. I am doing a Rollover/Direct Rollover of: [ ] CASH: [ ] all available cash or [ ] specific amount $ [ ] IN-KIND ASSETS: Please complete Section D below if you are rolling over assets in-kind.* *Note: Distributing and rolling over assets in-kind refers to the process of reregistering an asset with the proper vesting for your Quest IRA account. For example, as Quest IRA Inc. FBO [Account Holder s Name] IRA# [Account Number]. Value: Page 1 of 2

5 E. TYPE OF ROLLOVER PLEASE SELECT ONE OF THE FOLLOWING: Part 1. Rollover From Another Roth IRA Roth IRA Rollover Form 1. This rollover contribution is being made within 60 days after my receipt of funds from another Roth IRA in which I was either the participant or surviving spouse beneficiary. In the case of a distribution from a Roth IRA due to a first time homebuyer which is being rolled into this Roth IRA because of a delay in the acquisition of the first time home, this contribution is being made within 120 days after my receipt of funds from the distributing Roth IRA. 2. During the 12-month period prior to my receipt of the distribution being rolled over, I have not received a distribution from the same Roth IRA, which was subsequently rolled over to another Roth IRA, and the distribution being rolled over has not been part of a distribution from another Roth IRA that was subsequently rolled over. (This rule does not apply to a delay in the acquisition of a residence for a first time homebuyer.) Part 2. Conversion From Traditional IRA to Roth IRA 1. If an amount was distributed from a traditional IRA, this conversion contribution is being made within 60 days after my receipt of funds from my traditional IRA. Part 3. Rollover From a Designated Roth Contribution Account This is a [ ] direct rollover or a [ ] 60-day rollover from the Designated Roth Contribution Account under my employer s 401(k) or 403(b) plan, and I certify that the following statements are true and correct: 1. I certify that my employer s qualified 401(k) plan or 403(b) plan has made or will make an Eligible Rollover Distribution that is either being paid in a Direct Rollover to the Custodian of my Roth IRA, or paid directly to me that I am rolling over to my Roth IRA no later than the 60th day after receiving the Eligible Rollover Distribution. 2. This rollover/direct rollover solely represents all or a portion of my Designated Roth Contribution Account under the employer s plan and no other account under the employer s plan is being rolled over to my Roth IRA. 3. This rollover/direct rollover is not part of a series of payments over my life expectancy or over a period of 10 years or more. 4. This rollover/direct rollover does not include (1) any required minimum distribution with respect to the employer s plan; (2) any hardship distribution; (3) any corrective distribution; or (4) any deemed distribution from an employer s plan. 5. I certify that I am eligible to establish a Roth IRA with this rollover/direct rollover of an Eligible Rollover Distribution from a Designated Roth Contribution Account, and that I am one of the following: the plan participant; the surviving spouse of the deceased plan participant; the spouse or former spouse of the plan participant under a Qualified Domestic Relations Order; or a nonspouse beneficiary but only if this is a direct rollover to an Inherited Roth IRA. Part 4. Rollover Conversion From an Employer s Plan to Roth IRA 1. This rollover conversion contribution is being made within 60 days after my receipt of funds from my employer plan or is being paid in a direct rollover. 2. I understand that the taxable portion of this rollover conversion is includible in my gross income. 3. I certify that I am eligible to make a conversion. Part 5. Rollover Contribution of the Military Death Gratuity and SGLI Payments [ ] I certify that the following statements are true and correct and that I am the recipient of one or both of the following eligible rollover payments: 1. This rollover contribution is being made within one year after my receipt of a military death gratuity payment and does not exceed $100, This rollover contribution is being made within one year after my receipt of a SGLI payment and does not exceed $400,000. F. SIGNATURE OF ACCOUNT HOLDER NewAccounts@QuestIRA.com The undersigned hereby irrevocably elects, pursuant to IRS Regulation 1.402(a)(5)-1T to treat this contribution as a rollover contribution. I acknowledge that, due to the complexities involved in the tax treatment of rollovers between Roth IRAs, conversions from traditional IRAs and employer plans, rollovers from a Designated Roth Contribution Account under an employer s plan and rollovers of the military death gratuity and SGLI payments, has recommended that I consult with my tax advisor or the IRS before completing this transaction to make certain that this transaction qualifies as a valid contribution and is appropriate in my individual circumstances. I understand that these transactions are reported to the IRS and I acknowledge that I am responsible for record keeping Roth IRA contribution information as directed by the IRS. I hereby release and the Custodian from any claim for damages on account of the failure of this transaction to qualify as a valid rollover contribution or conversion. Signature of Account Holder: Date: Page 2 of 2