Bank Ira Form – Fill Out and Use This PDF

Premiere Select® IRA

Distribution Request

Account Number

Transaction ID  Broker Use Only

Check one.

If changing a periodic distribution plan, complete ONLY sections with changes and sign in Section 8.

 One-Time Distribution  Complete Sections 2, 3, 5, 6 and 8.

 Periodic Distributions  Complete Sections 2, 4, 5, 6, 7 and 8.

Refer to instructions for  further information.

Future Process Date  Optional

Check A and/or B or C, then provide any required information.

Refer to instructions for  further information.

  Gross Up  Optional. Increase partial cash distribution to include any taxes and transaction fees.

Indicate the 

number of shares or check “All.”

Fractional shares can be requested for mutual funds only.

B. Partial Distribution In-Kind

Redeposit as Current Year Contribution  Optional

=

Distribute to you

Check one, A through F, and complete the Frequency of Periodic Distribution Payments.

Type of Plan

 B. Fixed Period Plan

Deplete the entire balance over:

No. of Years

If you select C, you must choose Single or Another individual’s life expectancy.

Complete if applicable.

   C. IRA BDA Life Expectancy Plan  Refer to instructions for default provisions if choices in this section are left blank.

  Single life expectancy of account owner   Another individual’s life expectancy:

Date of Birth  MM DD YYYY

Check one. 

Complete if applicable. 

 Single Life Expectancy of account owner

 Joint Life Expectancies of account owner and beneficiary

 Include last year’s 12/31 market value of an outstanding rollover, transfer, or recharacterization amount:

Amount

$

.

   Calculate and distribute first year RMD on:

Date MM DD YYYY (Jan 1 - Apr 1 ONLY)

  Include last year’s 12/31 market value of an outstanding rollover, transfer, or recharacterization amount:

  RMD PLUS – increase your annual RMD by the amount of:

  Current Year RMD Adjustment – decrease your current year RMD amount by the following amount already distributed to you this year:

  F.  Earnings Plan

Amount

$

Amount

$

Amount

$

.

.

.

Check if applicable.

Check one.

Refer to the instructions for specific information on when payments will be made for Earnings Plans.

  Change existing Dividend, Interest, and Capital Gains Instructions to pay ALL mutual funds’ dividends and capital gains and ALL eligible securities’ dividend, interest, and capital gains in cash.

Frequency of Periodic Distribution Payments

Provide the Month and  Month/Year  MM YYYY Year of the first withdrawal

(Effective Date).

Provide the Month and  Month/Year  MM YYYY

Year of the final plan

withdrawal (End Date).

Optional.

NOT applicable if requesting a Fixed Period Plan.

Check one and  provide additional

details, as applicable, in this section.

 A. Check Distribution

 B. Electronic Funds Transfer (EFT)

 C. Bank Wire  Eligible for one-time distributions ONLY.

 D. Distribution to a Nonretirement Account (via Journal)

Check one,  if applicable.

  Use standing instructions on file

OR

Line Number

If you have multiple standing instructions, obtain the line number from your investment representative.

Information provided in  the Memo field will print

on the check but will not appear visible in the window of the envelope.

Additional Information  Not applicable when using standing instructions.

Memo  maximum 30 characters

Check Stub Information  maximum 100 characters

3rd Party Check  Paid and/or mailed to an alternate name(s) and/or address.

Check one. 

Use standing instructions on file

OR

Line Number

If you have multiple standing instructions, obtain the line number from your investment representative.

Avoid any account number or SSN that compromises a customer’s identity. If needed, use the Memo and Check Stub Information fields.

Optional. Information  provided in the Memo

field will print on the check but will not appear visible in the window of the envelope.

Alternate Instructions Not applicable when using standing instructions.

Payee

Specify overnight carrier and billing account

number. 

Carrier Address  required for UPS only

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Line Number

If you have multiple standing instructions, obtain the line number from your investment representative.

ONLY available for  one-time distributions.

Check one. 

Obtain the correct  routing number from the

bank. Different routing numbers may be used for Bank Wires and EFT transactions.

Alternate Instructions  Not applicable when using standing instructions.

Check one.

Check one.

C. Bank Wire  Available for one-time distributions ONLY. Choose 1st Party Bank Wire or 3rd Party Bank Wire and provide additional details as applicable.

A wire fee of $15 will be deducted from your distribution amount and will impact your tax reporting. Refer to the instructions for more information.

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.

Alternate Instructions Not applicable when using standing instructions.

Obtain the correct routing number from the bank.

Different routing numbers may be used for Bank Wires and EFT transactions.

Use to provide an additional message to receiving bank.

Use for wiring through an intermediary bank.

If account is outside the U.S., provide this information.

Details

D. Distribution to a Nonretirement Account (via Journal)

  Use standing instructions on file Available for one-time distributions ONLY.

OR

  Distribute to the following account:

Line Number

Account Number

If you have multiple standing instructions, obtain the line number from your investment representative.

Check one in each column. IRA owner’s legal/residential address determines which state’s tax rules apply.

Federal

Do NOT withhold federal taxes

Withhold federal taxes at the rate of:

State

Do NOT withhold state taxes unless required by law Withhold state taxes at the minimum rate Withhold state taxes at the rate of:

.0%

Check A, B or C.

A. Fixed Percentage – 100% from the core account

B.Fixed Percentage – From the money market mutual funds and/or other mutual funds in the percentages noted below:

Use whole number  percentages only.

Total must add up to 100%.

C. Proportional – From the core account AND all money market mutual funds and other mutual funds proportionately

Check A or B.

A. From any money market mutual fund position

B. From any money market mutual fund and then other mutual fund positions

By signing below, you:

•  Authorize and request National Financial Services LLC (“NFS”) to make the above distributions from the IRA indicated above.

•  Certify that the information supplied on this form is complete and accurate.

•  Represent that, to the extent you have requested a distribution due to disability, you meet the meaning of disabled, as indicated in IRC Section 72(m)(7).

•  Confirm, if you are taking a one-time distribution and you are not a U.S. person, you have previously submitted IRS Form W-8BEN.

•  Certify that you have carefully read, fully understand, and agree to comply with, the Customer Instructions, Terms and Conditions including the Notice of Withholding attached to this Premiere Select IRA Distribution Request.

•  Acknowledge, if requesting distributions via EFT, that NFS cannot verify the account registration at the receiving institution.

•  Indemnify Fidelity Management Trust Company and NFS, and their officers, directors, employees, agents, affiliates, shareholders, successors, assigns and representatives from any liability in connection with following the instructions in this form, including any liability in the event that you fail to meet the IRS requirements regarding distributions from your IRA.

Read these Instructions, Terms and Conditions carefully before completing and signing the attached form. You are responsible for complying with IRS rules governing IRA distributions, including required minimum distributions and substantially equal periodic payments. If you fail to meet any IRS requirements regulating IRA distributions, you may be subject to tax penalties. If you have any questions regarding your specific situation, consult with a tax advisor.

Upon depletion of all assets in your IRA, a $95 liquidation/termination fee and a final year annual maintenance fee, if applicable, as described in your Premiere Select Retirement Account Customer Agreement

or in some other manner acceptable to the Custodian, if applicable, will be collected from the final distribution amount. If you request a distribution that will result in an account balance that is less than the amount of any fees due, which include the liquidation/termination fee and the annual maintenance fee, for a particular year, NFS may instead process a full distribution of your entire account balance and collect the applicable fees at that time. Note that this could result in a payment amount that is less than the amount requested due to the payment of the applicable fees. In addition, your account may be closed.

If you have any questions, consult your Broker, Financial Advisor or Investment Professional (“investment representative”).

If you have inherited IRA assets from a decedent and wish to take death distributions, you must first establish and transfer the assets to an IRA BDA or Roth IRA BDA as applicable, then take the death distributions from the IRA BDA or Roth IRA BDA. If you are a spouse beneficiary and wish to transfer the decedent’s IRA to your IRA, do not complete this form; you must complete a Premiere Select IRA Transfer Request for Spouse Beneficiary, which can be obtained from your investment representative.

If you are under age 59½ and are taking distributions from your SIMPLE IRA before the expiration of the two-year period beginning on the date your employer makes the first contribution to your SIMPLE IRA, you may be subject to a 25% penalty.

If you wish to request a transfer pursuant to a divorce or separation of the IRA owner, do not complete this form. Contact your investment representative for additional instructions.

If you wish to request an IRA or IRA BDA Transfer of Assets (trustee- to-trustee transfer) to an IRA or inherited IRA/IRA BDA with another institution, do not complete this form. Contact your investment representative for additional instructions.

3. One-Time Distribution

Completing the Form

Write the IRA account number in the boxes in the upper right-hand corner of the form.

1. Account Owner

Complete this section as appropriate and indicate whether you are requesting a one-time distribution or a periodic distribution.

If establishing/changing/deleting a periodic distribution plan, check the appropriate box. If you are changing or deleting an existing periodic distribution plan that is one of multiple periodic distribution plans for the IRA indicated on the form, indicate the periodic distribution plan number provided by your investment representative.

2. Reason for Distributions

Indicate the reason for your distributions to ensure appropriate tax reporting, choosing only one. If you do not make a selection, your reason for distribution will be either “Normal” or “Premature” depending on your age as determined by your date of birth on record except for distributions from a BDA, which are processed as “Death Distributions.” Note that if you are under age 59½ and are taking distributions for a qualified first-time home purchase ($10,000 lifetime total), qualified higher education expenses, certain medical expenses or health insurance premiums, or substantially equal periodic payments, as defined in Internal Revenue Code (“IRC”) section 72(t), select the box for “Premature.” You may wish to consult with a tax advisor regarding the tax implications associated with each Reason for Distribution choice.

Important: SEPP distributions will be reported to the IRS as “premature distributions – no known exception applies.” If you qualify for an exception to the tax on premature distributions, you should file IRS Form 5329 with your tax return. Consult with your tax advisor for more information.

If you are requesting a qualified Roth IRA distribution, the account must meet the IRS requirement of the 5-taxable-year period. This period begins on (a) the first day of the taxable year for which the first regular contribution is made to any Roth IRA you own or (b) if earlier, the first day of the taxable year in which the first conversion contribution is made to any Roth IRA you own.

If you wish to request a direct Rollover to an Employer-Sponsored Retirement Plan, you must sign this form and the distribution must be paid directly to the qualified plan for the benefit of the participant. Provide the plan information (your name, your account number with the plan, and the plan name) in the third party payment method instruction. Sufficient details must be provided to allow the Employer- Sponsored Retirement Plan to apply the funds to your account.

If you wish to request disability distributions, refer to Section 72(m)(7) of the IRC for more information.

Future Process Date – Optional

You may specify a future process date for this distribution request (available for distributions in cash ONLY). For partial distributions, the future process date can be up to six months from the date the request is submitted EXCEPT for Return of Excess (ROE) contributions, which are limited to seven business days from the date the request is submitted. All full distributions are limited to seven business days from the date the request is submitted.

Note: The future process date cannot cross years; for an ROE of a contribution made in the prior year, it cannot go beyond the tax filing deadline (typically October 15); and for individuals who are under age 59½, it cannot be the date you turn age 59½ or beyond.

Distribution Instructions

For a distribution other than a Return of Excess Contribution, choose one 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 the balance in the core account. Provide a specific gross dollar amount to be distributed and select one payment method in the Payment Method section. If you want to gross up the distribution amount to include any 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 nonretirement brokerage account and provide the account number in the Payment Method 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 a separate 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, the value of the distribution will be grossed up to include any federal and state tax withholding. Tax withholding for distributions in kind will be withheld from the core account.

C. Full Distribution.* (Distribution of your entire IRA Balance)

•For a full distribution that is to be made in cash from your core account, select one payment method in the Payment Method section.

•For a full distribution to be made in-kind, provide the nonretirement brokerage account number in the Payment Method section.

*Note: Certain securities may only be issued in specified denominations. Return of Excess Contribution

Do NOT use this form to correct an excess contribution to a SIMPLE IRA. Contact your investment representative for information on how to request a return of excess contribution to a SIMPLE IRA.

If you wish to correct an excess contribution by requesting a return of the excess contribution, plus any applicable earnings, provide the date

on which the excess contribution was made, the tax year for which the excess contribution was made, and whether you are requesting the return of excess contribution before or after your tax filing deadline, including extensions for the year in which the excess contribution was made.

Contact your investment representative or tax advisor for information on how to determine the attributable earnings amount.

Redeposit as Current Year Contribution – Optional

If you wish to redeposit all or a portion of the excess contribution as a current year contribution,* you must specify the amount of the redeposit and the remainder to be distributed to you.** Note: The amount of the redeposit cannot exceed your current year allowable IRA contribution limit.

*Any amount to be distributed and then re-deposited as a current year contribution will be reported on an IRS Form 1099-R (for the distribution) and IRS Form 5498 (for the contribution).

**Payment will be made in accordance with the payment method selected in the Payment Method section and will be reported, less any wire fee, if applicable, on IRS Form 1099-R.

Note:

•You may be able to correct contributions to a Roth IRA by recharacterizing the Roth IRA contribution (and its earnings) to another IRA for the same tax year. Contact a tax advisor for more information on how to correct an excess Roth IRA contribution via recharacterization.

•If your employer makes a nondeductible contribution to your SEP-IRA, the excess amount is first treated as a regular annual IRA contribution and then to the extent the amount exceeds your annual IRA contribution limit, an excess occurs and can be corrected by requesting a return of excess contribution in this section of the form.

•A return of excess contribution (distribution) is not required if you are correcting the excess contribution by using the carry-over method of re-applying the excess contribution to subsequent tax years until the excess is depleted. Do not complete this form if you choose this option. Consult a tax advisor or your investment representative for more information.

•The amount of an excess contribution that is not distributed to you or applied to a subsequent year contribution by the tax filing deadline, including extensions, for the year in which the contribution was made, is subject to a 6% IRS penalty for each year that it remains in the IRA.

•Any applicable earnings distributed to you should be included as income in the year the contribution was made and may be subject to a 10% IRS early distribution penalty if you are under age 59½.

•If you elect to have federal and/or state income taxes withheld from the distribution, withholding will only apply (i) to the earnings that are specified if the distribution is processed prior to your tax filing deadline, including extensions, for the year in which the excess contribution was made, or (ii) to the entire amount of the distribution if the distribution is processed after your tax filing deadline, including extensions.

4. Periodic Distributions

Complete this section, choosing one of the six options listed.

A.  Fixed Amount Plan. Specify the dollar amount to be distributed each period.

B.  Fixed Period Plan. Indicate the number of years over which you wish to deplete your IRA. The amount of each payment will be calculated by dividing the total IRA balance by the remaining number of payments. For Premiere Select Traditional, Roth, Rollover, SEP and SIMPLE IRAs, each payment will be calculated based on the total balance of your IRA up to four business days before the distribution is scheduled. For IRA BDAs and Roth IRA BDAs, your annual payment amount will be calculated based on your prior year end total balance.

C.  IRA BDA Life Expectancy Plan. Life expectancy distributions from an IRA BDA are not a Required Minimum Distribution (RMD) calculation service. If you are establishing a periodic distribution plan to satisfy an RMD, consult with a tax advisor to ensure that the plan you establish, including the life expectancy information you provide, is applicable to your specific situation and satisfies your RMD requirements. Your distribution will be calculated based on your single life expectancy unless you choose to have your payments

based on another individual’s life expectancy, in which case you must provide that individual’s date of birth. Additional paperwork may be required; check with your investment representative.

If you are a spouse beneficiary, the annual payment amount will be calculated based on your single life expectancy based on your age in each distribution calendar year. If you are a non-spouse beneficiary, the annual payment will be calculated based on your current single life expectancy for the year following the original depositor’s date of death, which will be reduced by one year for each remaining calendar year distribution.

Distributions will be paid in equal installments in accordance with the payment frequency selected in the Frequency of Payments section.

If you wish to include last year’s 12/31 market value of an outstanding rollover, transfer, or recharacterization in the Life Expectancy calculation, provide the amount.

D.  Substantially Equal Periodic Payments (SEPP) Plan. You must be under age 59½. Any changes to the account balance after the SEPP plan is initiated will be deemed a modification and may result in IRS penalties. Once you begin taking payments, you cannot stop payments or change the calculation method until the later of five years or when you turn age 59½, with the exception that you can make a one-time change from the amortization calculation method to the required minimum distribution (RMD) calculation method; otherwise IRS penalties may be incurred.

•Calculation Method

Select the calculation method that you wish to use to calculate your SEPP payments.

Amortization Calculation Method Your SEPP distributions will be calculated by amortizing the prior December 31 balance of your IRA over the remainder of the life expectancy period that applies to the life expectancy election you make using the assumed rate of return you specify. IRS guidelines provide that the interest rate used be not more than 120% of the federal midterm rate for either of the two months immediately preceding the month distributions begin. Once the amount is calculated, the payment will remain constant.

Life Expectancy Calculation

Your annual SEPP amount will be calculated by dividing the prior December 31 balance of your IRA by the applicable factor based on the life expectancy election you make.

RMD Calculation Method Your annual SEPP amount will be calculated by dividing the prior December 31 balance of your IRA by the applicable factor from either the Uniform Distribution Table or the Joint Life Expectancy Table (for spousal exceptions only), as applicable. For SEPP plans established to distribute more than one payment per year, each payment is calculated by dividing the annual amount by the number of payments to be made in the year.

•  Life Expectancy Factor

Select either single life expectancy or joint life expectancy if you have selected the Amortization or Life Expectancy Calculation Method. NOT applicable if you selected the RMD Calculation Method.

If you wish to include last year’s 12/31 market value of an outstanding rollover, transfer, or recharacterization in the SEPP calculation, provide the amount.

Notes:

•  If you are requesting a change to an existing calculated SEPP plan, by completing and submitting this form, you are instructing NFS to calculate and distribute any remaining payments from your SEPP plan based on the information provided on this form, and the new calculation for each payment will take effect no later than 5 business days from the date that NFS receives and accepts the form in good order.

•  Any changes, other than a one-time calculation method change, to an existing calculated SEPP plan will result in the deletion

of the current plan, and the establishment of a fixed amount periodic distribution plan.

•  Payments will not be adjusted for any amounts distributed to you that are not part of the SEPP plan.

•  If you change your beneficiary designation at any time during the year by submitting a properly completed IRA Beneficiary

Designation form, you must inform NFS of the change, including the impact of such change on the requested SEPP calculations, by submitting another properly completed IRA Periodic Distribution Request form, and your payments may increase or decrease with payments beginning on January 1 of the year following the year of the beneficiary designation change.

Important: Changes to a beneficiary after the SEPP plan is initiated may cause a modification to the SEPP and may result in IRS penalties. Consult your tax advisor about your individual situation.

E.  Required Minimum Distribution (RMD) Plan or Roth IRA Life Expectancy Distribution Plan. (Not available to IRA BDAs) RMDs can be requested for Premiere Select Traditional, Rollover, SEP and SIMPLE IRAs. There is no requirement to take RMDs from Roth IRAs; however, you can request periodic distributions to be calculated based on the applicable life expectancy factor (“Roth IRA Life Expectancy distribution”). Your RMD/Roth IRA Life Expectancy distribution, including a first-year RMD that is being deferred to April 1 of this year or next year (if applicable), will be calculated using either the Uniform Distribution Table or the Joint Life Expectancy Table (for spousal exceptions only – see below), as applicable.

RMD Spousal Exception or Roth Joint Life Expectancy Calculation (”spousal exception”) Your payments will be calculated based on the spousal exception if your sole designated beneficiary for the entire distribution calendar year is your spouse who is more than 10 years younger than you. If the spousal exception applies, your distribution will be calculated based on your and your spouse’s joint life expectancies. Important: If the beneficiary designation on file with NFS indicates that you do not qualify for the spousal exception, your distribution will be calculated using the Uniform Distribution Table.

•  If you are deferring your first year RMD until between January 1 and April 1 of the year following the year you turn age 70½, check the box and provide the date to calculate and distribute your first year RMD. Note: The first distribution from the plan must be the deferred RMD.

•  If you wish to include last year’s 12/31 market value of an outstanding rollover, transfer, or recharacterization in the RMD/ Roth IRA Life Expectancy distribution calculation, provide the amount.

•RMD Plus. You may request an annual amount to be distributed to you in addition to your annual RMD/Life Expectancy payment amount. The amount you specify will be divided by the total number of remaining payments for the year and distributed in accordance with your instructions.

•  Current Year RMD Adjustment. You may request to decrease your annual RMD amount by an amount that has already been distributed to you for this year.

Notes:

•  RMD/Life Expectancy calculations will only include your IRA indicated on the form. If you maintain other IRAs, including those at other institutions, you are required to calculate your RMD for each IRA separately.

•  If you are establishing your periodic distribution plan mid-year, your entire RMD/Life Expectancy distribution for the current year will be paid out evenly over the remaining number of scheduled payments in the year.

•  If you maintain an RMD plan and if you change your beneficiary designation at any time during the year by submitting a properly completed IRA Beneficiary Designation form, you must inform NFS of the change, including the impact of such change to the requested RMD calculations by submitting another properly completed IRA Periodic Distribution Request form and your RMD amount may increase or decrease. If you fail to instruct NFS as to the impact of any beneficiary change, subsequent distributions in your payout plan may not satisfy your RMD requirements. Consult with your tax advisor to determine how a beneficiary change may affect your RMD amount.

F.  Earnings Plan

Distributions will be made from the core account based on the existing Dividend, Interest, and Capital Gains Instructions on your account unless you check this box to change the instructions to pay all eligible dividends and capital gains in cash.

Frequency of Periodic Distribution Payments

Periodic distributions will not be permitted more often than once per month.

Your periodic distribution plan will be activated in accordance with your instructions after this form is received in good order by NFS. Keep in mind mail and processing time when providing the Month and Year of the first withdrawal.

If a Month and Year of the first withdrawal are not provided, payment(s) will begin on the next scheduled pay date.

If no payment frequency is provided, payment(s) will be made annually in December.

The Day of the Month each withdrawal will occur must be the same day for each payment period. If no Day of the Month each withdrawal will occur is provided, payment(s) will be made on the 5th day of the month(s).

You may specify an end date for taking periodic distributions by providing the Month and Year of the final plan withdrawal. An end date is NOT applicable if you are requesting a Fixed Period Plan.

Notes:

•  Periodic distribution payments scheduled to be paid out in December may result in your distribution being processed prior to the date selected to help ensure that your distribution is processed prior to year end.

•  Periodic distribution payments scheduled to be paid out in early January may be delayed if year-end balance recalculations are required in computing the payment amount.

5. Payment Method

If no payment method is selected, your cash distributions will be made by check and sent to your mailing address of record (the first option described below).

A. Check Distribution

1st Party Check. Check will be paid and mailed to the name and mailing address of record. If you wish to use previously provided standing instructions, check the appropriate box.

3rd Party Check. If you want a check paid and/or mailed to a payee and/or address other than the mailing address of record, check this box. You may choose to use standing instructions already on file or you may provide Alternate Instructions for just this one distribution or plan. Note that Alternate Instructions will not be added to your account for use in any future distribution requests.

Overnight Mail. If you wish to have the check mailed via overnight delivery, provide the carrier name and billing number and, for UPS only, carrier address. Available for one-time distributions ONLY.

B. Electronic Funds Transfer (EFT)

1st Party EFT. If you would like the distributions to be deposited directly to your individually owned bank account (the name on the bank account and the IRA is the same), check this box.

3rd Party EFT. If you would like the distributions to be deposited to your joint bank account or a third-party bank account, check this box.

If you would like the distributions to be deposited directly to your bank via EFT, you must have EFT instructions on your account. If the account is not currently set up for standing EFT, a standing instructions form must be completed to establish the EFT instructions. Note: EFT may take 4–5 business days to become active. Business days are Monday through Friday. Bank and New York Stock Exchange holidays are not included. If you have multiple sets of standing instructions, provide the line number of the specific set of instructions, as it pertains to this situation. The line number can be obtained from your investment representative.

C. Bank Wire

In order to send a distribution via Bank Wire, the recipient institution must be a member of the Federal Reserve System. For 1st Party

or 3rd Party Wires, 1) you may choose to use standing instructions already on file, or 2) you may provide Alternate Instructions if this is a one-time distribution request.

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