Traditional/Roth IRA Distribution Request Form

Transcription

1 Traditional/Roth IRA Distribution Request Form 8051 E. Map717 17th Street, Ste Denver, CO PO Box Denver, CO fax Investment Manager Services, 2004 Page 1 of 5 IMS /04 Instructions, Definitions and General Information Section 1. Account Owner Information: Please complete all information requested. If information does not match the records of Investment Manager Services (IMS) or is left blank, the form will be returned to you with an explanation regarding the discrepancy or for completion.you must provide IMS with your residence address, not a P.O. Box. Federal income tax must be withheld from this distribution if you have not provided a U.S. residence address or if payment is being made outside the U.S. Section 2. Reason for Distribution: All distributions for Traditional IRAs and non-qualified Roth IRAs will be reported to the IRS on Form 1099-R based on your age, except for disability and substantially equal payments. If this distribution is for an individual under 59_ years old and you qualify for one of the following exceptions: medical expenses, education expenses, first time home purchase, or health insurance premiums for unemployed individuals, please consult your tax advisor regarding the completion of IRS Form 5329 in these instances. Premature: You are under 59_ years of age and may be subject to a 10% federal excise tax. Normal: You are over 59_ years of age. Disability: You are under 59_ years of age and meet the requirements as defined in IRC 72(m)(7). Substantially Equal Payments: It is your responsibility to determine the annual amount required. Required Minimum Distribution: If you are requesting IMS to calculate your minimum distribution, you must complete both Section 3 and the attached IRA Beneficiary Designation Form. Conversion of a Traditional IRA to a Roth IRA at IMS: If you wish to establish a Roth IRA with IMS, please complete a Roth IRA Application and submit it along with this distribution form. If you have an existing IMS Roth IRA, please write the account number in the space provided in Section 6E. Conversion of a Traditional IRA to a Roth IRA at another Trustee/Custodian: If you are requesting that IMS send your assets to a Roth account at another institution, please attach a copy of your existing Roth IRA account statement. You will also need to complete Section 6F. Qualified/Non-Qualified distribution from a Roth IRA: If you have questions regarding which choice is appropriate for your particular situation, please consult your tax advisor, the IRS or IRS Publication 590. IRA Direct Rollover to a Non-IRA Qualified Plan: For information please consult your tax advisor, the IRS or IRS Publication 590. Section 3. Required Minimum Distribution (RMD): Complete this section if you are requesting installment payments to meet your RMD. You must complete the attached Beneficiary Designation Form. If your sole beneficiary is a "qualifying trust," you must also provide a completed Trust Certification Form. Section 4. Tax Withholding: Even if you select "NOT" to have withholding, federal income tax must be withheld from this distribution if you have not provided a U.S. residence/street address (not a P.O. Box) in Section 1 or if payment is being sent to an address outside the U.S. Section 5. Payment Options: If you are requesting a total distribution, all installment payment schedules previously established will be stopped upon receipt of your request. You and your investment advisor must endure that enough cash is available to make each payment when due. Payments will continue until you notify IMS in writing to stop. Section 6. Payment Delivery: Choose one option and complete the requested information. If nothing is selected, we will send a check via first class mail to the mailing address referenced in Section 1. If you have selected ACH, please attach a voided check or a pre-printed deposit slip to the Traditional/Roth IRA Distribution Request Form. If not attached, IMS will send a check. Terms and Conditions of ACH Authorization: By electing an ACH Transfer in Section 6, your signature will constitute an acknowledgement that you have read and agree to the following: I hereby authorize Fiserv Trust Company/IMS to effect payment for my distribution by initiating credit entries to my account indicated at the financial institution named. I request such financial institution to accept any credit entries initiated by Fiserv Trust Company/IMS to such account and to credit the same such account without responsibility for the correctness thereof. I understand that such amounts will be debited as distributions from my retirement plan. (Please note that it can take up to three banking days after distribution for deposit to be made in your account.) I understand that this authorization may be terminated by me at any time by sending written notification to both my financial institution and to IMS. Any such notification to IMS shall be effective only with respect to entries to be initiated by IMS ten (10) calendar days or more after receipt of such notification. I may direct Fiserv Trust Company/IMS not to credit my financial institution account, provided that such authorization is in writing and is received by IMS not less than ten (10) calendar days prior to the initiation of the credit entry. There is no charge for this service. I agree to hold Fiserv Trust Company/IMS harmless from any consequences of acting in accordance with this authorization. (I understand that Fiserv Trust Company/IMS is not liable for the failure of a credit entry to be accepted by my financial institution.) Section 7. Fees: All applicable fees will be deducted from available cash prior to sending payment to the participant. If there is insufficient cash to cover the fees as well as the requested distribution amount, the fees will be collected from the available cash and the difference will be distributed to the participant.

2 IMS (Traditional/Roth) Distribution Request Form (continued) TRADITIONAL AND ROTH IRA FEES Termination Fee $50 IRA Trustee Fee Wire Fee Overnight Fee $25 (if applicable) $10 next day / $50 same day $10 (Saturday delivery $25 / only as requested.) Section 8. Signature: Sign and date the form to acknowledge all provisions on the Tradtional/Roth IRA Distribution Request Form and, if applicable, the Terms and Conditions of ACH Authorization in Section 6. A Medallion signature guarantee may be obtained from an authorized officer of a brokerage firm, bank or other specified financial institution. If this section is incomplete, the form will be returned to you for completion. Please make a copy of your form for your records. Investment Manager Services, 2003 Page 2 of 2 IMS-3154 (10/04)

3 Traditional/Roth IRA Distribution Request Form Distributions are reported to the Internal Revenue Service. You should consult your tax advisor or IRS Publication 590 concerning your distribution elections. Use this form for Traditional and Roth IRA distributions and Required Minimum Distributions. Do not use this form to recharacterize a Roth IRA contribution to a Traditional IRA contribution, request a return of an excess contribution, or if you are the beneficiary of an account. Other forms are required for these requests. 1. Account Information (Please type or print all information requested below.) Account Owner Name IMS Account Number 8051 E. Map717 17th Street, Ste Denver, CO PO Box Denver, CO fax Investment Manager Services, 2004 Social Security Number Date of Birth Daytime Telephone Number Residence Address (cannot be a P.O. Box) Mailing Address (if different than above) Type of Account (check one): Traditional IRA Roth IRA 2. Reason For Distribution (If no option is checked, we will default to premature or normal based on your age, for Traditional IRAs, and Non-Qualified for Roth IRAs.) Premature Normal Disability Substantially Equal Payments Required Minimum Distribution Conversion of a Traditional IRA to Roth IRA at IMS Conversion of a Traditional IRA to a Roth IRA with another Trustee Qualified Distribution from a Roth IRA Non-Qualified Distribution from a Roth IRA IRA Direct Rollover to a Non-IRA Qualified Plan (Must complete Section 6F.) 3. Required Minimum Distribution Election (RMD): Complete this section if you are requesting installment payments to meet your RMD. You must complete the attached Beneficiary Designation Form. If your sole beneficiary is a "qualifying trust," you must also provide a completed Trust Certification Form. Yes No Is your spouse more than 10 years younger than you and your sole beneficiary? Yes No You have designated a "qualifying trust" as your sole beneficiary and your spouse is the sole beneficiary of that trust and he/she is more than 10 years younger than you. 4. Tax Withholding (Choose one. If no option is checked, we will withhold 10% from the entire distribution.) I elect NOT to have federal income tax withheld. Withhold % or $ from my requested distribution (must be at least 10%). Notice of Withholding on Distributions Or Withdrawals From IRAs This notice is required to be furnished to you by IRS regulations each time an IRA distribution is requested. The distributions you receive from your retirement plan are subject to federal income tax withholding.you are liable for payment of federal income tax on the taxable portion of your distribution regardless of whether you elect to have tax withheld. If you have provided First Trust Corporation/IMS your residence address within the United States, you may elect not to have withholding apply. The amount withheld will be based on your entire distribution. If you have not provided us with your residence address or if you have provided a residence address outside of the United States, withholding generally is required and you cannot elect out of withholding. If you are eligible (as explained above), you may elect not to have withholding apply to your distribution payments by completing this distribution request form, specifically Section 4, or the tax withholding section of another distribution request form or IRS Form W-4P and returning it to IMS. 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. If you intend to make a rollover deposit of the distribution you are receiving, you should consider the election not to have tax withheld. You may change future scheduled distribution elections by completing an IRS Form W-4P or resubmitting another Distribution Request Form with updated information. Page 3 of 5 IMS /04

4 Traditional/Roth IRA Distribution Request Form (continued) 5. Payment Options (Please select at least one option. If this section is left blank, this form will be returned to you for complection. If you choose the option under "Total," you may not use any options under "Partial" or "Installment Payments." If you want to receive a partial distribution as well as establish an installment payment schedule, select an option under both sections.) Total Distribution (Your account will be closed.) Liquidate all assets, listed in Section 6, distribute all cash and close my account. Reregister all assets ( in kind ) to the IMS account number given in Section 6. Partial Distribution (Your account will remain open.) Send my current cash balance, leaving my other assets in the account. Send $ from my cash balance. Installment Payments (Your account will remain open. Only cash payments are allowed as directed in my payment schedule below:) Send me regular payments of $. Calculate and send my required minimum distribution based on the elections made in Section 3. Payment Schedule (Payments will be issued on the 15th of the month or the prior business day if the 15th falls on a weekend.) Monthly Semiannually Quarterly Annually Payments should begin on: / Month Year 6. Payment Delivery (Choose one and complete the requested information. If nothing is selected, we will send a check via first class mail to the mailing address of record specified in Section 1. Instructions to send cash anywhere other than to the address of record must be Medallion Signature Guraranteed in Section 8.) A. Mail a check to my address of record. Overnight delivery? Yes No B. Mail a check to: Overnight delivery? Yes No Name Address C. Electronic Funds Transfer (Choose one and complete the information below.) Wire: Complete the section below with bank routing and account number information or attach a voided check for your bank wire information. ACH Transfer: Attach a voided check or preprinted deposit slip to this form. Failure to attach the requested document will result in IMS sending you a check via first class mail to the address listed in Section 1. Please read the Terms and Conditions of ACH Authorization in the Instructions, Definitions and General Information. (Note: ACH transfers can be used only for installment payments.) Type of account (check one): Checking Savings Financial Institution Name Financial Institution Account Number Financial Institution Routing/ABA# Sub Account # (If applicable, for wires only.) ( ) Telephone Number D. Deposit the requested distribution in my IMS Custodial Account #. E. Deposit the requested distribution into my IMS Roth IRA Account # Investment Manager Services, 2004 Page 4 of 5 IMS-3154 (10/04)

5 Traditional/Roth IRA Distribution Request Form (continued) F. Send distribution to a Roth IRA or a non-ira retirement plan. (Qualified Retirement Plans, 401(k), 403(b)(7), etc.) Receiving Firm Name Tax ID Number Account Number ( ) Telephone Number Mailing Address X Successor Trustee Acceptance Signature (Please attach a corporate resolution.) Name (Printed) Title 7. Fees I understand that the requested distribution(s) will be subject to the fees outlined in Section 7 of the attached disclosure and that all applicable fees will be deducted from available cash prior to sending payment. 8. Signature I hereby acknowledge that I have read, understand and agree to all of the provisions of this Distribution Request Form, and if applicable, the ACH Authorization contained in Section 6 of the Instructions, Definitions and General Information. Instructions to send cash anywhere other than to the address of record must be Medallion Signature Guaranteed below. X Account Owner Signature Date Upon completion of this form, return to: Investment Manager Services P.O.Box Denver, CO or fax to Medallion Guarantee Stamp Here Investment Manager Services, 2004 Page 5 of 5 IMS-3154 (10/04)