Dear Custmer: Thank yu fr cntacting Custmer Care regarding the clsure f yur Individual Retirement Accunt (IRA). In rder t prcess yur request, please cmplete the enclsed Request fr Distributin frm. Yu may return the dcuments in the enclsed pstage-paid envelpe, r fax them t us at 302.791.5788. The clsure prcess n yur accunt will begin upn receipt f all 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n Frm 1099-R. In accrdance with IRS regulatins, yu may be required t pay federal and state taxes and/r a penalty n withdrawn funds.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 and applicable fees: Payment Optins Check Payable t Accunt Hlder* N charge Electrnic Funds Transfer (ACH) $5.00 Maintain IRA with The Bancrp (cntact us fr ptins) N charge** Wire (cmpleted Wire Transfer Request frm is required) $25.00 Transfer t Anther Financial Institutin (include transfer paperwrk, if required by receiving institutin) $12.00*** Fee * A check payable t the accunt hlder will be autmatically sent if n ther ptin is selected. ** Accunt set-up is free, but an annual fee may apply based upn type f accunt established. Terms and Cnditins, as well as a Schedule f Fees, are available at www.thebancrpbank.cm. *** If yur financial institutin des nt require additinal paperwrk t be included with yur distributin check, the transfer fee is nt applicable. Activity Accunt Clsing Fee (Fee t clse yur IRA within the first year.) Annual Fee (Fee assessed annually t maintain yur IRA accunt.) Maintenance Fee (Fee assessed when the first depsit is made t yur accunt.) $25.00 $20.00 $20.00 Fee Fr additinal infrmatin and instructins, please see the enclsed dcuments: Checklist f Dcuments t Be Returned and Instructins fr Cmpleting the IRA Distributin Request Frm IRA Distributin Request frm Substitute Frm W-4P Withhlding Certificate fr IRA Distributins If yu have any questins, please cntact us at 866.540.9364. Sincerely, Custmer Care
Checklist f Dcuments t Be Returned If adequate dcumentatin is nt received, yu will be cntacted by a representative f The Bancrp Bank with further instructins. What Is Required: Cmpleted IRA Distributin Request frm (see instructins belw) Prf f identity and address. Please send us a clear phtcpy f yur current, unexpired driver s license r ther gvernment-issued identificatin (bth sides, if signed n the back). Nte: If the address n the item submitted des nt match yur current address, yu must als prvide a clear phtcpy f (1) a lease agreement signed and dated within the past 12 mnths r (2) a utility bill, bank statement r insurance statement generated within the past 30 days. If the name n the item submitted des nt match yur current name, please cntact us fr instructins. Instructins fr Cmpleting the IRA Distributin Request Frm Part 1: IRA Owner Infrmatin: Cmplete this sectin in full. Nte: The address must match the address n yur driver s license r ther dcumentatin yu prvide fr prf f address. 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: Tax Withhlding Electin (Traditinal IRAs nly): Select whether yu wuld like t have incme tax withheld. If yu pt t have tax withheld, be sure t specify a percentage. Part 4: Payment Instructins: Review the ptins and select ne. The available payment ptins are: One-Time Payment by Check: Use this sectin t initiate a rllver r transfer t anther financial institutin, r t request that a check be sent t yu. Nte: Check with yur ther financial institutin t determine whether it requires dcumentatin t accmpany the check. One-Time Payment by Wire Transfer: Prvide infrmatin abut the receiving financial institutin. Payment by ACH: Prvide infrmatin abut the receiving financial institutin. Part 5: Signature: Please read, sign, and date the frm. Please mail r fax yur dcuments t: The Bancrp ATTN: Fulfillment 409 Silverside Rad Suite 105 Wilmingtn, DE 19809 Fax: 302.791.5788
IRA DISTRIBUTION REQUEST 409 Silverside Rad, Suite 105 Wilmingtn, DE 19809 P: 866.540.9364 F: 302.791.5788 www.thebancrpbank.cm 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 Distributin Request frm and include ALL apprpriate dcumentatin as utlined in the Checklist f Dcuments t be Returned. We will begin prcessing yur request nce all required dcumentatin has been received by the Bank. PART 1: IRA Owner Infrmatin First Name: MI: Last Name: Accunt Number: SSN: DOB: Address: City: State: Zip Cde: Hme Phne: Mbile Phne: Email: 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 5329. 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 5329. T claim an exceptin frm the premature distributin penalty, yu must cmplete IRS Frm 5329, available at www.irs.gv. Yu must file that frm with yur tax return. D nt send t it 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 t yur emplyer 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 financial institutin infrmatin sectin. Inherited IRA distributin: The riginal IRA wner has died, and I am the beneficiary. Please prvide death certificate. Additinal dcumentatin will be required. Other, please explain This ptin shuld be chsen fr thse claiming disability r anther specific reasn nt included as an ptin abve.
IRA Distributin Request Page 2 f 4 PART 3: Mandatry Tax Withhlding Requirements Traditinal IRAs Only We encurage yu t cnsult with yur accuntant r tax advisr regarding yur IRA distributins. Yu may be subject t tax penalties under the estimated mandatry tax payment rules utlined in the chart belw, if yur payments f estimated tax and withhlding are nt accurate as prvided in the illustratin. Nte: Any federal and applicable state taxes withheld will be deducted frm the ttal requested distributin amunt. (Example: Distributin requested = $10,000; Taxes withheld = $1,000 (10%); Payment = $9,000) Federal Taxes Nte: If n federal withhlding electin is indicated, IRS regulatins require that 10% federal tax withhlding be taken frm yur distributins. D nt withhld federal incme tax frm my IRA distributins. Withhld federal incme tax f % (at least 10%) frm my IRA distributins. State Taxes Nte: If n State Tax withhlding electin is indicated, IRS regulatins require that the chart belw be fllwed. If yu reside in ne f the states that has mandatry withhlding, thse funds will be withheld frm yur distributins. D nt withhld state incme tax frm my IRA distributins. Withhld state incme tax f % frm my IRA distributins. (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 Yur ptins fr state tax withhlding are: Mandatry Mandatry nly if yu elect federal tax withhlding Prhibited Residents f all ther states Fr states nt referenced in the table, please cnsult with yur tax advisr as we DO NOT ffer a state and the District f Clumbia withhlding ptin. State law is subject t change, which may affect the accuracy f this illustratin. Nte: If the distributin is frm a Rth IRA, it may be exempt frm state tax. Cnsult with yur accuntant r tax adviser t btain the mst up-t-date infrmatin n yur state s requirements. (Cntinue t Part 4 n next page)
IRA Distributin Request Page 3 f 4 PART 4: Payment Instructins Please cmplete nly ne sectin belw. ONE-TIME CHECK PAYMENT Attach cmpleted Transfer f Assets frm, if required by the receiving financial institutin. Distributin amunt: Nte: Tax withhlding electins may reduce the ttal amunt received. See Part 3 abve. Balance f accunt. Delivery methd: Standard delivery Mailing instructins: Send t my address listed abve Overnight delivery* Receiving financial institutin infrmatin** ($12.00 fee applies) Name f receiving IRA trustee/custdian: Name f IRA wner: Address: City: State: Zip: *Additinal fee f $50 will apply fr expedited delivery services, please cnsult the Schedule f Fees fr mre details. ** Attach cmpleted Transfer f Assets frm, if required by the receiving financial institutin. ONE-TIME WIRE TRANSFER ($25.00 wire 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. Please fill ut yur name and address in this sectin if yu are requesting a wire: Accunt Name: (must be in same name as IRA wner) Accunt Number: Accunt Hlder Address: ABA Ruting Number: First Name: Last Name: City: State: Zip: Phne: Reference: Scial Security Number: (last 4 digits) ONE-TIME ACH PAYMENT Electrnic Transfer t Nn-Retirement Accunts nly ($5.00 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 Financial Institutin Name: Accunt Number: Accunt Name: (must be in same name as IRA wner) ABA Ruting Number: City: State: Zip: Phne: FOR BANK USE ONLY Custmer s Authrized Rep.: Call-Back Verificatin Date: Call-Back Verificatin Time: Wire Rm Verificatin by: (initials) Wire Transfer Entered by: (initials) Wire Transfer Verified by: (initials) Date Prcessed: Apprved by: (signature)
IRA Distributin Request Page 4 f 4 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 frm a previus plan spnsr. In rder fr The Bancrp t prcess my distributin request, I authrize the Bank t rder cnsumer reprts abut me/us 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/us in respnse t such inquiries. TIN Certificatin 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; and (3) I am a U.S. citizen (r a U.S. resident alien); and (4) I am exempt frm FATCA reprting. CERTIFICATION INSTRUCTIONS: Yu must crss ut Item 2, abve, 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. 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)
SUBSTITUTE FORM W-4P Department f the Treasury Internal Revenue Service Withhlding Certificate fr IRA Distributins OMB N. 1545-0074 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 1-800-TAX-FORM (1-800-829-3676) 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 www.irs.gv. 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. 505. 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 6103. W-4PS 01/2010