Broker Use Only IRA One-Time Distribution Request

Transcription

PrintResetAccount NumberTransaction ID Broker Use OnlyPremiere Select IRAOne-Time Distribution RequestUse this form to request a one-time distribution from your Premiere Select Traditional, Roth, Rollover, SEP or SIMPLE IRA, IRA BeneficiaryDistribution Account (BDA) or Roth IRA BDA, referred to as “IRA” or “account,” held through National Financial Services LLC (“NFS”). Forsome transactions, standing instructions must be on file prior to submitting this request. Complete the Premiere Select Standing PaymentInstructions form to establish those instructions.Read the attached Customer Instructions, Terms and Conditions before completing this form. Type on screen or fill in using CAPITAL lettersand black ink. If you need more room for information use a copy of the relevant page and include the account number, your signature and the date.1. Account OwnerFirst NameM.I.Last NameSocial Security Number2. Distribution RequestRefer to instructionsfor default provisionsif you do not make achoice in this section.Check one.Reason for DistributionDo NOT use this distribution form for the purposes of purchasing an Alternative or Specialized Investment in your IRA. Normal Current age is 59½ or older. Premature Current age is under 59½.Skip to Section 3. Return of Excess Contribution(s) Rollover From your IRA paid directly to an employer-sponsored retirement plan for the benefit of you, theparticipant. Do not use this form for an IRA trustee to trustee transfer. Disability Disabled as defined in IRC Section 72(m)(7) and current age is under 59½. Death distribution Taking a distribution from an IRA BDA or Roth IRA BDA.Distribution InstructionsCheck A and/orB or C, thenprovide any requiredinformation. A. Partial Distribution in CashTransaction fees may apply and could reduceamount of request.Amount .B. Partial Distribution In-KindIndicate the number of shares orcheck “All.”Fractional shares can berequested for mutualfunds only.Investment NameInvestment NameInvestment NameOptional when selecting a partial distribution.Refer to instructions forfurther information.CUSIP or SymbolCUSIP or SymbolCUSIP or SymbolNumber of Shares/ALL. ALL. ALL. ALLNumber of Shares/ALLNumber of Shares/ALL Gross Up Increase partial distribution amount provided in A or B above to include any taxes and transaction fees.C. Full Distribution Distribute entire IRA balance.1.894238.103Page 1 of 5021490401

3. Return of Excess ContributionComplete this section if Return of Excess Contribution(s) was chosen in Section 2.Date on which excess contribution was made:Date MM DD YYYYCheck one. Tell us when you arerequesting the return ofexcess contribution.For Tax Year YYYY Before your tax filing deadline Including extensions. After your tax filing deadline Including extensions.Distribute the following excess contribution amount and attributable earnings, as indicated below.Distribute to youPrincipal AmountTotal Amount Principal EarningsEarnings Amount. . . Redeposit as Current Year Contribution OptionalReturn of excess contributions are distributed to you unless requested to be redeposited as a current year contributionthat does not exceed the allowable current year contribution.The combined total of Redeposit as current year contributionthese boxes must equalCurrent Year Amountthe total amount in the Principal Earnings.box above.4. Payment MethodDistribute remainder to youDistribution Amount .Choose one. Not applicable if electing 100% tax withholding.Distribution to a Nonretirement AccountUse standing instructions on fileLine NumberDistribute to the following account:Account NumberIf you have multiple standinginstructions, obtain the line numberfrom your investment representative.ORCheck DisbursementCheck A or B. A. 1st Party Check Paid and mailed to name and mailing address on record.Check one, if applicable.Use standing instructions on fileLine NumberIf you have multiple standinginstructions, obtain the line numberfrom your investment representative.OR Additional InformationNot applicable when using standing instructions.Information provided in the Memo field will printon the check but willnot appear visible in thewindow of the envelope.Memo maximum 30 charactersCheck Stub Information maximum 100 characters B. 3rd Party Check Paid and/or mailed to an alternate name(s) and/or address.continued on next page1.894238.103Page 2 of 5021490402

4. Payment MethodCheck one. continuedone. Not applicable if electing 100% tax withholding.ChooseUse standing instructions on fileIf you have multiple standinginstructions, obtain the line numberfrom your investment representative.Line NumberOR Alternate InstructionsNot applicable when using standing instructions.Avoid any accountnumber or SSN thatcompromises a customer’sidentity. If needed, usethe Memo and CheckStub Information fields.PayeeAttention maximum 32 characters total including "Attn:"Care of maximum 32 characters total including "C/O"ORAttn:C/OAddressCityState/ProvinceZip/Postal CodeMemo maximum 30 charactersOptional. Information provided in the Memofield will print on thecheck but will not appearvisible in the window ofthe envelope.Check Stub Information maximum 100 charactersOvernight Mail Optional for Check Disbursements ONLYYour distribution check will be sent via regular mail unless you check this box and provide overnight mail instructions.Overnight MailSpecify overnight carrier and billingaccount number.Carrier NameCarrier Account NumberCarrier Address required for UPS onlyElectronic Funds Transfer (EFT)When using EFT, allow 2-3 business days after the date the distribution is processed for funds to reach your bank orcredit union.Check A or B. A. 1st Party EFT The name on the bank account and the IRA is the same.To transfer funds via 1st Party EFT, you MUST have EFT standing instructions on your account.If you have multiple standing instructions, obtain the line number fromyour investment representative.Line Number B. 3rd Party EFT The name(s) on the bank account and the IRA is (are) different.Use standing instructions on fileLine NumberORIf you have multiple standinginstructions, obtain the line numberfrom your investment representative. Alternate InstructionsNot applicable when using standing instructions.Check one. Obtain the correct routing number from thebank. Different routingnumbers may be usedfor Bank Wires and EFTtransactions. CheckingBank Routing Number SavingsBank NameBank Account NumberOwner(s) Name(s) Exactly as on Bank Accountcontinued on next page1.894238.103Page 3 of 5021490403

4. Payment MethodChoose one.continuedNot applicable if electing 100% tax withholding.Bank WireA wire fee of 15 will be deducted from your distribution amount and will impact your tax reporting. Refer to theinstructions for more information.Check one. 1st Party Bank Wire The name on the bank account and the IRA is the same. 3rd Party Bank Wire The name(s) on the bank account and the IRA is (are) different.Check one.Use standing instructions on fileIf you have multiple standinginstructions, obtain the line numberfrom your investment representative.Line Number Alternate InstructionsNot applicable when using standing instructions.Obtain the correct routing number from the bank.Different routing numbersmay be used for Bank Wiresand EFT transactions.Bank Routing NumberUse to provide an additional message to receiving bank.DetailsUse for wiring through an intermediary bank.If account is outside the U.S., provide thisinformation.Bank NameBank Account Number Final destinationOwner(s) Name(s) Exactly as on Bank Account 3rd party onlyFurther Credit Account NumberFurther Credit NameSWIFT CodeDestination Country5. Tax Withholding ElectionsComplete this section only if you are a U.S. person (including a U.S. resident alien). The tax withholding elections below will apply to thisdistribution only. Read the Notice of Withholding in the Customer Instructions, Terms and Conditions before completing this section.Federal Income Tax WithholdingCheck one.If no election is made, orif the percentagerate entered is less than10%, federal income taxwill be withheld from yourdistributions at a rateof 10% (Roth IRAand Roth IRA BDAdistributions excluded). Do not withhold federal income tax from the IRA distribution. Withhold federal income tax from the IRA distribution at the percentage rate of:Specify a whole number percentage between 10% and 100%.Percentage.0%State Income Tax WithholdingCheck one.Do not make an election ifyou are a resident of AK,FL, HI, MS, NH, NV, SD,TN, TX, WA, or WY.The state of residencein the legal address onthis IRA will determinethe state income taxwithholding requirementsfor your distribution. o not withhold state income tax from the IRA distribution. For residents of CA, NC, and OR, this box must beDchecked if federal income taxes are being withheld and you do not want state income taxes withheld. For residentsof DE, this box must be checked regardless of whether or not federal income taxes are being withheld if you donot want state income taxes withheld. ithhold state income tax from the IRA distribution in accordance with the minimum amount or percentage,Wif any, as determined by the requirements of your state of residence. If your state does not provide a minimumamount or percentage for withholding and a specific percentage was not provided in the section below, stateincome taxes will not be withheld from your distribution.Withhold state income tax from the IRA distribution at the percentage rate of:Percentage.0%1.894238.103Specify a whole number percentage between 1% and 100%.If the percentage rate entered is less than your state’sminimum withholding requirements, your state’s minimumamount or percentage will be withheld.Page 4 of 5021490404

6. Signature and DateForm cannot be processed without signature and date.By signing this form, you: Authorize and request National FinancialServices LLC (“NFS”) to make the abovedistribution from the IRA indicated above. Certify that the information supplied on thisform is complete and accurate. Represent that, to the extent you haverequested a distribution due to disability,you meet the meaning of disabled, asindicated in IRC Section 72(m)(7). Certify under the penalties of perjury that,if you are a U.S. citizen or other U.S. person(including a resident alien individual), thenumber shown in Section 1 of this form isyour correct taxpayer identification number(or Social Security number) and, if you arenot a U.S. person (including a U.S. residentalien), you have previously submitted IRSForm W-8BEN and included your U.S.taxpayer identification number (or SocialSecurity number) in order to claim tax treatybenefits, if applicable. Certify that you have carefully read, fullyunderstand, and agree to comply with theCustomer Instructions, Terms and Conditions,including the Notice of Withholding attachedto this Premiere Select IRA One-TimeDistribution Request. A cknowledge, if requesting a distributionvia EFT, that NFS cannot verify the accountregistration at the receiving institution. Indemnify Fidelity Management TrustCompany and NFS, and their officers,directors, employees, agents, affiliates,shareholders, successors, assigns andrepresentatives, from any liability inconnection with following the instructions inthis form, including any liability in the eventthat you fail to meet the IRS requirementsregarding distributions from your IRA.Either the account owner or an authorized signatory must print name, sign, and date.Print Account Owner Name First, M.I., LastDatemm - dd - yyyyDatemm - dd - yyyySIGNAccount Owner SignatureORPrint Authorized Signatory Name First, M.I., LastSIGNAuthorized Signatory SignaturePrintNational Financial Services LLC, Member NYSE, SIPC1.894238.103Page 5 of 51.894238.103 - 520929.4.0 (02/14)021490405Reset

Premiere Select IRA One-Time Distribution RequestCustomer Instructions, Terms and ConditionsRead these Instructions, Terms and Conditions carefully beforecompleting and signing the attached form. You are responsiblefor complying with IRS rules governing IRA distributions, includingrequired minimum distributions and substantially equal periodicpayments. If you fail to meet any IRS requirements regulating IRAdistributions, you may be subject to tax penalties. If you have anyquestions regarding your specific situation, consult with a tax advisor.The attached form should be used to request a one-time distributionfrom a Premiere Select Traditional, Roth, Rollover, SEP or SIMPLE IRA,IRA Beneficiary Distribution Account (BDA) or Roth IRA BDA, referredto as “IRA” or “account,” held through National Financial ServicesLLC (“NFS”).If you wish to request a distribution from more than one IRA, youmust complete a separate form for each IRA.Distributions made in cash will be paid from the balance of your coreaccount investment vehicle (“core account”). It is your responsibilityto ensure there are sufficient funds available in the core account toprocess the distribution. If there are insufficient funds available in thecore account, the distribution will not be processed.For full distributions, a 95 liquidation/termination fee and a final yearannual maintenance fee, if applicable, as described in your PremiereSelect Retirement Account Customer Agreement or in some othermanner acceptable to the Custodian, if applicable, will be collectedfrom the final distribution amount. If you request a distribution thatwill result in an account balance that is less than the amount of anyfees due, which include the liquidation/termination fee and the annualmaintenance fee, for a particular year, NFS may instead process a fulldistribution of your entire account balance and collect the applicablefees at that time. Note that this could result in a payment amountthat is less than the amount requested due to the payment of theapplicable fees. In addition, your account may be closed.If you have any questions, consult your Broker, Financial Advisor orInvestment Professional (“investment representative”).Completing the FormWrite the IRA account number in the boxes in the upper right-handcorner of the form.1. Account OwnerComplete this section as appropriate.2. Distribution RequestReason for DistributionIndicate the reason for your distribution to ensure appropriate taxreporting, choosing only one. If you do not make a selection, yourreason for distribution will be either “Normal” or “Premature”depending on your age as determined by your date of birth onrecord except for distributions from a BDA which are processedas “Death Distributions.” Note that if you are under 59½ and aretaking a distribution for a qualified first-time home purchase ( 10,000lifetime total), qualified higher education expenses, certain medicalexpenses or health insurance premiums, or substantially equal periodicpayments, as defined in Internal Revenue Code (“IRC”) section 72(t),select the box for “Premature.” You may wish to consult with your taxadvisor regarding the tax implications associated with each Reason forDistribution choice.If you are requesting a qualified Roth IRA distribution, the account mustmeet the IRS requirement of the 5-taxable-year period. This periodbegins on (a) the first day of the taxable year for which the first regularcontribution is made to any Roth IRA you own or (b) if earlier, the firstday of the taxable year in which the first conversion contribution ismade to any Roth IRA you own.If you wish to request a direct Rollover to an Employer-SponsoredRetirement Plan, you must sign this form and the distribution must bepaid directly to the qualified plan for the benefit of the participant.Provide the plan information (your name, your account number withthe plan, and the plan name) in the third party payment methodinstruction. Sufficient details must be provided to allow the EmployerSponsored Retirement Plan to apply the funds to your account.If you wish to request a disability distribution, refer to section 72(m)(7)of the Internal Revenue Code (IRC) for more information.If you have inherited IRA assets from a decedent and wish to takedeath distributions, you must first establish and transfer the assets toan IRA BDA or Roth IRA BDA as applicable, and then take the deathdistributions from the IRA BDA or Roth IRA BDA. If you are a spousebeneficiary and wish to transfer the decedent’s IRA to your IRA, donot complete this form: You must complete a Premiere Select IRATransfer Request for Spouse Beneficiary, which can be obtained fromyour investment representative. If you are a spouse beneficiary whohas transferred inherited IRA assets to your own IRA and are requiredto take the decedent’s year of death Required Minimum Distribution(RMD), you may take the RMD directly from your IRA after the transferhas been processed.If you are under age 59½ and are taking distributions from your SIMPLEIRA before the expiration of the two-year period beginning on the dateyour employer makes the first contribution to your SIMPLE IRA, youmay be subject to a 25% penalty.If you wish to request a transfer pursuant to a divorce or separation ofthe IRA owner, do not complete this form. Contact your investmentrepresentative for additional instructions.If you wish to request an IRA or IRA BDA Transfer of Assets (trusteeto-trustee transfer) to an IRA or inherited IRA/IRA BDA with anotherinstitution, do not complete this form. Contact your investmentrepresentative for additional instructions.Distribution InstructionsFor a distribution other than a Return of Excess Contribution, chooseone of the three options listed (For a Return of Excess Contribution,refer to the Return of Excess Contribution section below):A. Partial Distribution in Cash. The distribution will be paid from thebalance in the core account. Provide a specific gross dollar amount tobe distributed and select one payment method in the Payment Methodsection. If you want to gross up the distribution amount to includeany federal and state tax withholding and any wire fee (as applicable),check the Gross Up box.B. Partial Distribution In-Kind.* Provide the investment name(s),and share/unit amount(s) to be re-registered into a nonretirementbrokerage account and provide the account number in the PaymentMethod section. If more space for investment information is needed,list the information requested on the form along with your name,account number and Tax Identification/Social Security number on aseparate sheet of paper, sign and date it and attach it to the form.If you are requesting a partial distribution in kind of shares only, thevalue of the distribution will be grossed up to include any federaland state tax withholding. Tax withholding for distributions in kindwill be withheld from the core account. If you are requesting a partialdistribution of cash and shares, and would like to gross up the amountto include any federal or state tax withholding, check the Gross Upbox.C. Full Distribution.* (Distribution of your entire IRA Balance) For a full distribution that is to be made in cash from your coreaccount, select one payment method in the Payment Method section. For a full distribution to be made in-kind, provide the nonretirementbrokerage account number in the Payment Method section.* Note: Certain securities may only be issued in specifieddenominations.Page 1 of 4

3. Return of Excess ContributionDo NOT use this form to correct an excess contribution to a SIMPLEIRA. Contact your investment representative for information on how torequest a return of excess contribution to a SIMPLE IRA.If you wish to correct an excess contribution by requesting a return ofthe excess contribution, plus any applicable earnings, provide the dateon which the excess contribution was made, the tax year for which theexcess contribution was made, and whether you are requesting thereturn of excess contribution before or after your tax filing deadline,including extensions for the year in which the excess contributionwas made.You mu

Premiere Select IRA One-Time Distribution Request 1.894238.103 Account Number Transaction ID Broker Use Only Use this form to request a one-time distribution from your Premiere Select Traditional, Roth, Rollover, SEP or SIMP