IRA Form Instructions

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1 IRA Form Instructions 1

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3 Tabe of Contents Section Page Number IRA Designation or Change of Beneficiary Form for Traditiona and Roth IRAs... 4 IRA Contribution Instructions for Traditiona and Roth IRAs... 6 IRA Roover or Conversion Review for Traditiona and Roth IRAs... 8 IRA Request for the Direct Roover to a Roth IRA IRA Request for the Direct Roover to a Traditiona IRA IRA Request for Transfer or Conversion to an IRA for Traditiona and Roth IRAs IRA Distribution Form for Traditiona and Roth IRAs Pease Read: IRS Circuar 230 Discosure: Discover Bank and its affiiates do not provide tax advice. Accordingy, any discussion of U.S. tax matters contained herein (incuding any attachments) is not intended or written to be used, and cannot be used, in connection with the promotion, marketing or commendation by anyone unaffiiated with Discover Bank of any of the matters addressed herein or for the purpose of avoiding U.S. tax-reated penaties. 3

4 IRA Designation or Change of Beneficiary Form for Traditiona and Roth IRAs: Sampe IRA Designation or Change of Beneficiary Form for Traditiona, Roth, and SIMPLE IRAs IRA OWNER INFORMATION NAME, ADDRESS, CITY, STATE, AND ZIP Traditiona IRA SIMPLE IRA Discover Bank PO Box Sat Lake City, UT (888) (801) Fax TYPE OF IRA (check one): Roth IRA IRA ACCOUNT (PLAN) NUMBER SOCIAL SECURITY NUMBER DATE OF BIRTH DAYTIME PHONE NUMBER DESIGNATION OF BENEFICIARY (See Additiona Information incuded with this form.) At the time of my death, the primary beneficiaries named beow wi receive my IRA assets. If a of my primary beneficiaries die before me, the contingent beneficiaries named beow wi receive my IRA assets. In the event a beneficiary dies before me, such beneficiary's share wi be reaocated on a pro-rata basis to the other beneficiaries which share the deceased beneficiary's cassification as a primary or contingent beneficiary. If a of the beneficiaries die before me, my IRA assets wi be paid to my estate. If no percentages are assigned to beneficiaries, the beneficiaries wi share equay. If the percentage tota for each beneficiary cassification type does not equa 100 percent, any remaining percentage wi be divided equay among the beneficiaries within such cass. This designation revokes and supercedes a earier beneficiary designations which may appy to this IRA. A. Primary Beneficiary PERCENTAGE % % % Tota 100% NAME OF BENEFICIARY SSN OR TAXPAYER IDENTIFICATION NUMBER RELATIONSHIP TO IRA OWNER BENEFICIARY DATE OF BIRTH B. Contingent Beneficiary PERCENTAGE NAME OF BENEFICIARY SSN OR TAXPAYER IDENTIFICATION NUMBER RELATIONSHIP TO IRA OWNER BENEFICIARY DATE OF BIRTH % % - % Tota 100% SPOUSAL CONSENT Community or marita property state aws may require spousa consent for a nonspouse beneficiary designation. The aws of the state in which the financia organization is domicied, the IRA owner resides, the trust is ocated, the spouse resides, or this transaction is consummated shoud be reviewed to determine if such a requirement exists. Spousa consent for the beneficiary designation may aso be required by financia organization poicy.... I Am Married. I understand that if I designate a primary beneficiary other than my spouse, my spouse must consent by (IRA Owner Initias) signing beow.... I Am Not Married. I understand that if I marry in the future, I must compete a new Designation of Beneficiary form, which (IRA Owner Initias) incudes the spousa consent documentation. I am the spouse of the IRA owner. Because of the significant consequences associated with giving up my interest in the IRA, the custodian/trustee has not provided me with ega or tax advice, but has advised me to seek tax or ega advice. I acknowedge that I have received a fair and reasonabe discosure of the IRA owner's assets or property and any financia obigations for a community property state. In the event I have a ega interest in the IRA assets, I hereby give to the IRA owner such interest in the assets hed in this IRA and consent to the beneficiary designation set forth in Section 2 of this form.... Signature of Spouse SIGNATURES I certify that the information provided on this form is accurate and compete. I hereby agree to the terms and conditions set forth in Sections 2 and 3. I agree that I am responsibe for any caims that may arise as a resut of my seections, incuding naming beneficiaries other than my spouse. I understand that my IRA agreement, discosure statement, and amendments thereto, may provide me with additiona guidance. I agree that the custodian/trustee cannot give me ega advice. I reease the custodian/trustee from and indemnify the custodian/trustee for a caims that may arise from my actions reated to this form.... Signature of IRA Owner 1998 Woters Kuwer Financia Services - Bankers Systems* Form IRACMBCNGLAZ Rev. 10/1/ Signature of Witness (if required) (Witness cannot be a beneficiary of this IRA)... Discover Bank, Custodian Signature Custodian/Trustee of (page 1 of 2) 4

5 IRA Designation or Change of Beneficiary Form for Traditiona and Roth IRAs: Instructions Section 1. IRA Owner Information: Pease print the requested information: Compete a fieds in this section incuding your socia security number and date of birth. Seect the type of IRA you are requesting your distribution from. Section 2. Designation of Beneficiary: Primary Beneficiary (A): If married, you must designate your spouse as your primary beneficiary uness your spouse provides spousa consent. Provide a requested information for both Primary and Contingent Beneficiaries, if any, incuding fu name, socia security number, reationship and date of birth. Section 3. Spousa Consent: Section 4. Signatures: Initia in the appropriate marita status fied; If I Am Married is seected and the spouse is not the designated beneficiary, the spouse must sign and date the form to be considered a vaid request. Designation or Change of Beneficiary form must be signed and dated by the IRA owner to be considered a vaid request. First initias, short names or nicknames wi not be accepted. 5

6 IRA Contribution Instructions for Traditiona and Roth IRAs: Sampe About Printing Requirements Reset Show Fied Borders IRA Contribution Instructions for Traditiona, Roth, and SIMPLE IRAs IRA OWNER INFORMATION NAME, ADDRESS, CITY, STATE, AND ZIP Discover Bank PO Box Sat Lake City, UT (888) (801) Fax IRA ACCOUNT (PLAN) NUMBER SOCIAL SECURITY NUMBER DATE OF BIRTH DAYTIME PHONE NUMBER TRADITIONAL IRA CONTRIBUTION INVESTMENT NUMBER CONTRIBUTION TYPE: ROTH IRA CONTRIBUTION INVESTMENT NUMBER CONTRIBUTION TYPE: SIMPLE IRA CONTRIBUTION Reguar (incuding Catch-Up) Simpified Empoyee Pension (SEP) Pan Recharacterization Roover Transfer $ Reguar (incuding Catch-Up) Roover Transfer Recharacterization Conversion $ $ AMOUNT AMOUNT Empoyer Contribution Recharacterization (See Additiona Information incuded with this form.) CONTRIBUTION DATE Roover/Direct Roover from an Eigibe Retirement Pan Quaified Reservist/Designated Disaster Distribution Repayment* Disaster/Combat Zone Postponed Contribution* *Reason Code (if appicabe) (See Additiona Information incuded with this form.) CONTRIBUTION DATE TAX YEAR Roover/Direct Roover from an Eigibe Retirement Pan Roover/Direct Roover from a Designated Roth Account Quaified Reservist/Designated Disaster Distribution Repayment* Disaster/Combat Zone Postponed Contribution* *Reason Code (if appicabe) (See Additiona Information incuded with this form.) Roover from a SIMPLE IRA Transfer from a SIMPLE IRA TAX YEAR TAX YEAR OF FIRST ROTH IRA CONTRIBUTION/CONVERSION INVESTMENT NUMBER AMOUNT CONTRIBUTION DATE TAX YEAR INITIAL CONTRIBUTION DATE CONTRIBUTION TYPE: EMPLOYER INFORMATION NAME, ADDRESS, CITY, STATE, AND ZIP (For SEP or SIMPLE contributions.) TAXPAYER IDENTIFICATION NUMBER DAYTIME PHONE NUMBER SIGNATURES I certify that I am the IRA owner, empoyer, or individua egay authorized to compete this form. I certify the accuracy of the information set forth in this form, and I authorize this transaction. I certify that this contribution is eigibe for deposit, and I assume fu responsibiity for determining my eigibiity and for ensuring the eigibiity of the contribution. My designation of the tax year for the contribution, and any eection to treat a contribution as a roover or recharacterization, is irrevocabe. I indemnify and agree to hod the custodian/trustee harmess from any resuting iabiities. I acknowedge that the custodian/trustee cannot provide, and has not provided, me with tax or ega advice. I have been advised to seek the guidance of a tax or ega professiona. Signature of IRA Owner/Empoyer Discover Bank, Custodian Custodian/Trustee Signature of Custodian/Trustee IRA Contribution Instructions for Traditiona, Roth, and SIMPLE IRAs IRACMBCONLAZ 1/1/2011 Bankers Systems* Woters Kuwer Financia Services 1998, 2011 Page 1 of 3-6

7 IRA Contribution Instructions for Traditiona and Roth IRAs: Instructions Section 1. IRA Owner Information: Pease print the requested information: Compete a fieds in this section incuding your address, account number, socia security number and date of birth. Section 2. Traditiona IRA Contribution: If you are contributing to a Roth IRA account, pease skip to Section 3. If you are contributing to a Traditiona IRA account. Section 3. Roth IRA Contribution: Provide your Discover IRA account number, amount of contribution, date of contribution and the tax year the contribution is to be appied. Seect the contribution type. If you are contributing to a Roth IRA account. Provide your Discover IRA account number, amount of contribution, date of contribution and the tax year the contribution is to be appied. Seect the contribution type. Section 4. SIMPLE IRA Contribution: This section does not appy, pease skip. Section 5. Empoyer Information: Section 6. Signatures: This section does not appy, pease skip. The Contribution Instructions Form must be signed and dated by the IRA Owner to be considered a vaid request. First initias, short names or nicknames wi not be accepted. 7

8 IRA Roover or Conversion Review for Traditiona and Roth IRAs: Sampe IRA Roover or Conversion Review for Traditiona, Roth, and SIMPLE IRAs IRA OWNER INFORMATION NAME, ADDRESS, CITY, STATE, AND ZIP Discover Bank PO Box Sat Lake City, UT (888) (801) Fax IRA ACCOUNT (PLAN) NUMBER SOCIAL SECURITY NUMBER DATE OF BIRTH DAYTIME PHONE NUMBER ROLLOVER OR CONVERSION ELIGIBILITY REVIEW Compete A, B, C, D, or E. (For further expanation see Additiona Information incuded with this form.) } If "No" is checked, a roover generay cannot occur. A. Roover from a (check one): Traditiona IRA to a Traditiona IRA SIMPLE IRA to a Traditiona IRA Roth IRA to a Roth IRA SIMPLE IRA to a SIMPLE IRA Yes No I am competing this roover within 60 days of receiving my distribution. I have met the requirements of the one roover per 12-month rue. I am eigibe to make this roover contribution. Assets ineigibe for roover incude any required minimum distribution, distributions to a nonspouse beneficiary, or any part of a series of substantiay equa periodic payments. (For SIMPLE IRAs ony) At east two years have passed since the date of the initia contribution to my SIMPLE IRA. B. Roover or Direct Roover from a Quaified Pan (QP), Tax-Shetered Annuity (TSA), or 457(b) Pan to a Traditiona IRA. Yes No I have received an eigibe roover distribution from an Interna Revenue Code Section 401(a), 403(a), 403(b), or governmenta 457(b) pan. (For roovers ony) I am competing this roover within 60 days of receiving my distribution. I am eigibe to make this roover contribution. Assets ineigibe for roover incude any required minimum distribution, any part of a series of substantiay equa periodic payments, a pan oan in defaut, certain dividends on empoyer securities, P.S. 58 costs of ife insurance, a corrective distribution of certain excess contributions, or any hardship distribution. C. Roover or Direct Roover from a Designated Roth Account to a Roth IRA. Yes No I have received an eigibe roover distribution from an Interna Revenue Code Section 401(a) or 403(b) pan. (For roovers ony) I am competing this roover within 60 days of receiving my distribution. I am eigibe to make this roover contribution. Assets ineigibe for roover incude any required minimum distribution, any part of a series of substantiay equa periodic payments, a pan oan in defaut, P.S. 58 costs of ife insurance, a corrective distribution of certain excess contributions, or any hardship distribution. D. Roover or Direct Roover from an Eigibe Retirement Pan to a Roth IRA. Yes No I have received an eigibe roover distribution from an Interna Revenue Code Section 401(a), 403(a), 403(b), or governmenta 457(b) pan. (For roovers ony) I am competing this roover within 60 days of receiving my distribution. I am eigibe to make this roover contribution. Assets ineigibe for roover incude any required minimum distribution, any part of a series of substantiay equa periodic payments, a pan oan in defaut, certain dividends on empoyer securities, P.S. 58 costs of ife insurance, a corrective distribution of certain excess contributions, or any hardship distribution. E. Conversion to a Roth IRA from a (check one): Traditiona IRA SIMPLE IRA Yes No (For conversions by roover ony) I am competing this conversion within 60 days of receiving my distribution. I am eigibe to make this conversion contribution. Assets ineigibe for conversion incude any required minimum distribution, any part of a series of substantiay equa periodic payments, or any corrective distribution of certain SEP or SIMPLE IRA pan excess contributions. (For SIMPLE IRAs ony) At east two years have passed since the date of the initia contribution to my SIMPLE IRA. IRA Roover or Conversion Review for Traditiona, Roth, and SIMPLE IRAs IRACMBROLLAZ 1/1/2010 Bankers Systems* Woters Kuwer Financia Services 1998, 2010 Page 1 of 3-8

9 IRA Roover or Conversion Review for Traditiona and Roth IRAs: Instructions SIGNATURES I certify that I am the IRA owner or individua egay authorized to compete this form. I certify the accuracy of the information set forth in this form. I understand that my roover or direct roover eection is irrevocabe. I assume fu responsibiity for the consequences of this roover or conversion decision. I indemnify and agree to hod the custodian/trusteeharmess against any resuting iabiities. I acknowedge that the custodian/trusteecannot provide, and has not provided, me with tax or ega advice. I have been advised to seek the guidance of a tax or ega professiona. Discover Bank, Custodian Signature of IRA Owner Custodian/Trustee Signature of Custodian/Trustee Section 1. IRA Owner Information: Pease print the requested information: Compete a fieds in this section incuding your account number, socia security number and date of birth. Section 2. Roover or Conversion Eigibiity Review: Section 3. Signatures: Answer Yes or No to the questions appicabe to your roover/conversion type. The Roover or Conversion Review Form must be signed and dated by the IRA Owner to be considered a vaid request. First initias, short names or nicknames wi not be accepted. 9

10 IRA Request for Direct Roover to a Roth IRA: Sampe About Printing Requirements Reset Show Fied Borders Request for Direct Roover to a Roth IRA ROTH IRA OWNER INFORMATION NAME, ADDRESS, CITY, STATE, AND ZIP Discover Bank PO Box Sat Lake City, UT (888) (801) Fax SOCIAL SECURITY NUMBER DATE OF BIRTH DAYTIME PHONE NUMBER DIRECT ROLLOVER REQUEST Source of Funds (seect one): Designated Roth Account Eigibe Retirement Pan (other than a Designated Roth Account) I authorize and direct you, as Pan Administrator of my empoyer's pan, to directy ro over the assets identified in the Direct Roover Instructions section to the Custodian/Trustee named in the upper right corner of this form. For a direct roover of assets from the pan, pease do not send the amount of any remaining required minimum distribution for the current year. PLAN ADMINISTRATOR NAME, ADDRESS, CITY, STATE, AND ZIP PLAN ACCOUNT NUMBER PHONE NUMBER NAME OF EMPLOYER'S PLAN DIRECT ROLLOVER INSTRUCTIONS (See Additiona Information incuded with this form). Compete my direct roover as instructed beow. Note: Penaties and market fuctuation may affect the distribution amount. A. Payment Amount (seect one): My entire account baance. A portion of my account baance. Describe B. Payment Schedue and Investments (seect one): Immediatey iquidate investments and send cash proceeds. Send a investments in kind. Send and/or iquidate the investments as identified beow: Account Number or Investment Doar Amount or Number of Shares Other Transaction Send: C. Deivery Instructions (1) Roth IRA Account (Pan) Number (2) Make check payabe to or certificate registration in the name of as custodian trustee for the Roth IRA of (3) Request for Direct Roover to a Roth IRA IRADIRORTHLZ 1/1/2010 Bankers Systems* Woters Kuwer Financia Services 2007, 2010 Page 1 of 3-10

11 IRA Request for Direct Roover to a Roth IRA: Instructions SIGNATURES I certify that I am the Roth IRA owner or individua egay authorized to compete this form. I acknowedge that I am eecting to make this direct roover by providing this request form. I certify the accuracy of the information set forth in this form, and I authorize this transaction. I understand the custodian/trustee may require me to provide and/or compete additiona documents before processing this transaction. I understand that my direct roover eection is irrevocabe. I indemnify and agree to hod the custodian/trustee harmess against any resuting iabiities. I acknowedge that the custodian/trustee cannot provide, and has not provided, me with tax or ega advice. I have been advised to seek the guidance of a tax or ega professiona. Signature of Roth IRA Owner Discover Bank, Custodian Custodian/Trustee Signature of Custodian/Trustee Section 1. Roth IRA Owner Information: Pease print the requested information: Compete a fieds in this section incuding your socia security number and date of birth. Section 2. Direct Roover Request: Seect either Designated Roth Account or Eigibe Retirement Pan from a Quaifying Retirement Pan or Another Eigibe Retirement Pan (Non-IRA). If you are unsure, pease consut your tax professiona or financia panner for guidance on the proper deposit source. Provide current Pan Administrator information (your current financia institution). Section 3. Direct Roover Instructions: Payment Amount; Section 4. Signatures: Seect the payment amount, Entire Baance or Portion of the Baance. Payment Schedue and Investments; Seect one of the payment schedues. Provide the Account Number or Investment, Doar Amount or Number of Shares,Transaction and seect. Deivery Instructions; Provide your Discover IRA account number. Provide the titing of the check Discover Bank as (seect custodian ) for the Roth IRA of (your name). Roover Eection form must be signed and dated by the IRA Owner to be considered a vaid request. First initias, short names or nicknames wi not be accepted. 11

12 IRA Request for Direct Roover to a Traditiona IRA: Sampe About Printing Requirements Reset Show Fied Borders Request for Direct Roover to a Traditiona IRA Discover Bank PO Box Sat Lake City, UT (888) (801) Fax IRA OWNER INFORMATION NAME AND ADDRESS (Custodian's/Trustee'sname, address, and phone number above) SOCIAL SECURITY NUMBER DATE OF BIRTH DAYTIME PHONE NUMBER DIRECT ROLLOVER REQUEST The pan administrator of my empoyer's pan shoud send the assets identified in the Direct Roover Instructions section. NAME OF EMPLOYER'S PLAN PLAN ADMINISTRATOR ADDRESS PLAN ACCOUNT NUMBER PLAN ADMINISTRATOR PHONE NUMBER DIRECT ROLLOVER INSTRUCTIONS (See Additiona Information incuded with this form.) Compete my direct roover as indicated. Note: Penaties and market fuctuation may affect the distribution amount. A. Payment Amount (seect one) My entire pan baance. A portion of my pan baance. $ B. Payment Schedue and Investments (seect one) Immediatey iquidate a investments and send cash proceeds. Send a investments in kind. Liquidate the investments as identified beow: Account Number or Investment Doar Amount or Number of Shares Transaction Send: Other SIGNATURES C. Deivery Instructions (1) IRA Account Number (2) Make check payabe to or certificate registration in the name of as custodian / trustee for the traditiona IRA of I certify that the information contained on this form is true and correct. I direct the pan administrator to send my assets as set forth in this form. I understand that my direct roover is irrevocabe. I understand I shoud seek the guidance of a tax or ega professiona with regard to this decision. I understand that if I estabish a separate conduit account, it is my responsibiity to keep my conduit account separate from my other accounts. I understand that my custodian/trustee cannot provide ega advice. I indemnify and agree to hod the custodian/trustee harmess against any iabiities. I assume fu responsibiity for the consequences of this direct roover decision.... Signature of IRA Owner... Discover Bank, Custodian Signature Custodian/Trustee of -2001Bankers Systems, Inc., St. Coud, MN Form IRA-DIRROLLZ 1/1/2002 (page 1 of 2) 12

13 IRA Request for Direct Roover to a Traditiona IRA: Instructions Section 1. Traditiona IRA Owner Information: Pease print the requested information: Compete a fieds in this section incuding your socia security number and date of birth. Section 2. Direct Roover Request: Provide current pan administrator information (your current financia institution). Section 3. Direct Roover Instructions: Payment Amount; Section 4. Signatures: Seect the payment amount, Entire Baance or Portion of the Baance. Payment Schedue and Investments; Seect one of the payment schedues. Provide the Account Number or Investment, Doar Amount or Number of Shares,Transaction and seect. Deivery Instructions; Provide your Discover IRA account number. Provide the titing of the check Discover Bank as (seect custodian ) for the Traditiona IRA of (your name). The Roover Eection form must be signed and dated by the IRA Owner to be considered a vaid request. First initias, short names or nicknames wi not be accepted. 13

14 IRA Request for Transfer or Conversion to an IRA for Traditiona and Roth IRAs: Sampe About Printing Requirements Reset Show Fied Borders Request for Transfer or Conversion to an IRA for Traditiona, Roth, and SIMPLE IRAs IRA OWNER INFORMATION NAME, ADDRESS, CITY, STATE AND ZIP Discover Bank PO Box Sat Lake City, UT (888) (801) Fax SOCIAL SECURITY NUMBER DATE OF BIRTH DAYTIME PHONE NUMBER (OPTIONAL) TYPE OF TRANSACTION Compete A or B. A. Transfer: B. Conversion: Traditiona IRA to a Roth IRA to a SIMPLE IRA to a SIMPLE IRA to a Traditiona IRA Roth IRA SIMPLE IRA Traditiona IRA Traditiona IRA to a Roth IRA (See Additiona Information incuded with this form.) SIMPLE IRA to a Roth IRA } Required minimum distributions cannot be converted to a Roth IRA. } If appicabe, the required minimum distribution has or has not been satisfied for this distribution year prior to this transfer. If not, the transferee custodian/trustee may require additiona documentation. } SIMPLE IRA funds cannot be transferred to a traditiona IRA or converted to a Roth IRA for two years foowing the date of the initia SIMPLE contribution. TRANSFEROR CUSTODIAN/TRUSTEE REQUEST My IRA custodian/trustee (transferor),, shoud transfer/convert the assets identified in the Transfer/Conversion Instructions section. TRANSFEROR ADDRESS, CITY, STATE AND ZIP TRANSFEROR PHONE NUMBER TRANSFEROR IRA ACCOUNT NUMBER - TRANSFER/CONVERSION INSTRUCTIONS (See Additiona Information incuded with this form.) Compete my transfer/conversion as directed. Note: Penaties and market fuctuation may affect the distribution amount. A. Payment Amount (seect one): B. Payment Schedue and Investments (seect one): My entire IRA baance. Immediatey iquidate investments and send cash proceeds. A portion of my IRA baance. $ Send a investments in kind. Send the assets at maturity for each of the investments. Liquidate the investments as identified beow: Account Number or Investment Doar Amount or Number of Shares Transaction Send: Other C. Deivery Instructions (1) Transferee IRA Account Number (2) Make check payabe to or certificate registration in the name of as custodian / trustee for the traditiona / Roth / SIMPLE IRA of. WITHHOLDING ELECTION (For Conversions Ony. See IRS Form W-8BEN if you are a foreign person.) The instructions to Form W-4P (Withhoding Certificate) are incuded in the Additiona Information section of this form. Form W-4P I eect not to have Federa income tax withhed from my IRA distribution. Department of the Treasury Interna Revenue Service I eect to have 10 percent Federa income tax withhed from my IRA distribution. OMB No I want the foowing additiona doar amount ($ ), or additiona percentage ( %) withhed from each IRA distribution. I eect to have $ or % State income tax withhed from my IRA distribution (if appicabe). SIGNATURES I certify that the information contained on this form is true and correct. I direct the transferor custodian/trustee to transfer or convert my IRA assets as set forth in this form. I understand I shoud seek the guidance of a tax or ega professiona with regard to this decision. I understand that if I estabish a separate conduit account, it is my responsibiity to keep my conduit account separate from my other accounts. I understand that my custodian/trustee cannot provide ega advice. I indemnify and agree to hod the custodian/trustee harmess against any iabiities. I assume fu responsibiity for the consequences of this transfer or conversion decision. The custodian/trustee agrees to accept these funds as a transfer or conversion. Discover Bank, Custodian Signature of IRA Owner Signature Custodian/Trustee of Transferee Custodian/Trustee * (page 1 of 2) 2001 Woters Kuwer Financia Services - Bankers Systems Form IRACMBTRCVLZ Rev. 2/1/

15 IRA Request for Transfer or Conversion to an IRA for Traditiona and Roth IRAs: Instructions Section 1. IRA Owner Information: Pease print the requested information: Compete a fieds in this section incuding your socia security number and date of birth. Section 2. Type of Transaction: Seect the type of Transfer/Conversion being requested. Section 3. Transferor Custodian/Trustee Request: Provide current Pan Administrator information (your current financia institution). Section 4. Transfer/Conversion Instructions: Payment Amount; Seect the payment amount, Entire Baance or Portion of the Baance. Payment Schedue and Investments; Provide the Account Number or Investment, Doar Amount or Number of Shares,Transaction and seect. Deivery Instructions; Section 5. Withhoding Eection: Section 6. Signatures: Provide your Discover IRA account number. Provide the titing of the check Discover Bank as (seect custodian) for the (seect type of IRA) of (your name). Ony fi out this fied for conversions by seecting the appropriate information. Seect the amount of Federa and/or State Tax you woud ike withhed from your distribution. For Conversions, seect the appropriate withhoding eection option; State tax rates are subject to change. Discover Bank recommends that you consut with your tax advisor regarding your tax withhoding eections. Regardess of the eection chosen, you are responsibe for ensuring the tax withhed combined with any estimated tax payments you choose to make are sufficient to meet federa and state tax payment requirements. The Transfer Request form must be signed and dated by the IRA Owner to be considered a vaid request. First initias, short names or nicknames wi not be accepted. 15

16 IRA Distribution Form for Traditiona and Roth IRAs: Sampe IRA Distribution Form for Traditiona, Roth, and SIMPLE IRAs IRA OWNER INFORMATION DATE OF BIRTH NAME, ADDRESS, CITY, STATE AND ZIP DATE OF DEATH (IF APPLICABLE) IRA ACCOUNT (PLAN) NUMBER SOCIAL SECURITY NUMBER (SSN) Discover Bank PO Box Sat Lake City, UT (888) (801) Fax DAYTIME PHONE NUMBER TYPE OF IRA (SELECT ONE) Traditiona IRA SIMPLE IRA Roth IRA Tax Year of First Roth IRA Contribution/Conversion: DISTRIBUTION REASON Seect One. (For further information, see Additiona Information incuded with this form.) For Traditiona, Roth, and SIMPLE IRAs Recharacterization of Contribution/Conversion for Tax Year Eary Distribution from a Roth IRA Correction of Excess Contribution for Tax Year Age 59½ or Oder (Norma for Traditiona IRAs) Amount of excess $ Death Earnings attributabe to excess (if appicabe) $ Disabiity On or before my tax-fiing due date, incuding extensions Revocation In same year as excess contribution Transfer to another IRA In year after excess contribution Prohibited Transaction After my tax-fiing due date, incuding extensions IRS Levy Quaified Heath Savings Account Funding Distribution (QHSAFD) For Traditiona and SIMPLE IRAs Ony Eary Distribution, no known exception Eary Distribution, exception appies NAME, ADDRESS, CITY, STATE AND ZIP Conversion. I am age 59½ or oder younger than age 59½. Direct Roover to an empoyer-sponsored Eigibe Retirement Pan SIMPLE IRA Distribution in Two-Year Period (if ess than age 59½) Recipient Information (Compete for IRS Levy, Death, Transfer, Recharacterization, Direct Roover, and QHSAFD transactions.) IRA ACCOUNT (PLAN) NUMBER (IF APPLICABLE) DAYTIME PHONE NUMBER TAXPAYER IDENTIFICATION NUMBER (TIN)/SSN (IF APPLICABLE) BENEFICIARY DATE OF BIRTH (IF APPLICABLE) PAYMENT INSTRUCTIONS PAYMENT ELECTION I eect distributions to be paid in the foowing manner (seect one): (1) Immediate Distribution of $. (2) (1) (2) Periodic Distribution I authorize automatic distributions of $ on a monthy annua quartery other basis, starting on. (3) Continue periodic distributions unti I notify you in writing otherwise. (3) Other (incuding transfers) PAYMENT METHOD Mai check to me. Deposited into my account at this financia organization. Account Type Account Number Other PAYMENT DETAIL (competed by financia organization) Amount Requested $ Penaties Charged (-) Administrative Fees Subtota (amount subject to withhoding) (-) $ Federa Income Tax Withhed (-) State Income Tax Withhed (if appicabe) (-) Loca Tax Withhed Net Amount Paid (-) $ Earnings paid to date not aready reported to IRA Administration Provider (optiona). Incude this figure in the Amount Requested. $ Does this distribution cose the IRA? Yes No of Distribution IRA Distribution Form for Traditiona, Roth and SIMPLE IRAs IRACMBDISLAZ 7/1/2009 Bankers Systems* Woters Kuwer Financia Services 1998, 2009 Page 1 of 4-16

17 IRA Distribution Form for Traditiona and Roth IRAs: Instructions WITHHOLDING ELECTION (Not Appicabe to Roth IRAs. See IRS Form W-8BEN if you are a foreign person.) W-4P The instructions to Form W-4P (Withhoding Certificate) are incuded in the Additiona Information section of this form. Form I eect not to have Federa income tax withhed from my IRA distribution. Department of the Treasury Interna Revenue Service I eect to have 10 percent Federa income tax withhed from my IRA distribution. OMB No I want the foowing additiona doar amount ($ ), or additiona percentage ( %) withhed from each IRA distribution. I eect to have $ or % State income tax withhed from my IRA distribution (if appicabe). SIGNATURES I certify that I am the IRA owner, the beneficiary, or individua egay authorized to compete this form. I certify the accuracy of the information set forth in this form, and I authorize this transaction. I understand the custodian/trusteemay require me to provide and/or compete additiona documents before processing any distributions. I assume fu responsibiity for any consequences associated with my distribution incuding any taxes and penaties owed. I indemnify and agree to hod the custodian/trusteeharmess from any resuting iabiities. I acknowedge that the custodian/trusteecannot provide, and has not provided, me with tax or ega advice. I have been advised to seek the guidance of a tax or ega professiona. Signature of IRA Owner/Beneficiary Discover Bank, Custodian Custodian/Trustee Signature of Custodian/Trustee Section 1. IRA Owner Information: Pease print the requested information: Compete a fieds in this section incuding your socia security number and date of birth. Seect the type of IRA you are requesting your distribution from. Section 2. Distribution Reason: Seect ony one reason from the options provided. Provide the recipient s information. Section 3. Payment Instructions: Seect ony one payment eection from the options provided; For Immediate distribution, provide the singe payment amount. For Periodic Distribution, provide the mutipe payment amount and seect the preferred distribution interva. Seect one payment method. If Deposited into my account at this financia organization is seected pease indicate the account type and number. Payment Detai shoud be fied out by your current financia institution. Section 4. Withhoding Eection: Section 5. Signatures: For Traditiona IRA distribution requests, seect the appropriate withhoding eection option; If you fai to make a withhoding seection, Discover Bank wi withhod a mandatory 10% for federa withhoding and any required state tax withhoding for your state. State tax rates are subject to change. Discover Bank recommends that you consut with your tax advisor regarding your tax withhoding eections. Regardess of the eection chosen, you are responsibe for ensuring the tax withhed combined with any estimated tax payments you choose to make are sufficient to meet federa and state tax payment requirements. Distribution form must be signed and dated by the IRA Owner / Beneficiary to be considered a vaid request. First initias, short names or nicknames wi not be accepted. 17

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20 2011 Discover Bank, Member FDIC IRAFORM.1111