Distribution Form – Fill Out and Use This PDF

		Easy IRA Distribution Request
		for Traditional and Roth IRAs
	Mail or Fax completed forms to:	Questions? Call us at 1-888-OUR-HRBB
	PO Box 2569, Omaha, NE 68103
	Fax: 866-812-3144
	Account Owner
	First Name (Print Clearly)
	
	Last Name (Print Clearly)
	
	Home Phone Number	Cell/Work Phone Number
	--	--
	SSN/TIN:	Email Address

--

Account Number



Payment Instructions

Required: Redemption Amount

 ALL (will result in a $25 termination fee)OR PARTIAL* $  ,   .  

*An Early Distribution may result in a substantial penalty. If an amount is not selected, a full balance distribution will be processed with a $25 Termination Fee. If the amount requested is greater than the account balance at time of request, an amount equal to the balance will be paid. If a partial payment is selected and the amount lowers your balance below the $25 minimum balance rule, a $25 termination fee will be applied and the remaining balance distributed to you.

Method of Payment

Mail check via regular mail to the following address (Please allow 10-14 days for delivery)	check here for
	 change of address

Express check to the following address. P.O. Box Address NOT allowed. ($25.00 fee) (Please allow 2-3 business delivery days)

Street (Print Clearly)



City (Print Clearly)

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StateZip Code

   - 

Create a one time ACH (Please allow 3-5 business days for delivery)

Account Number (Print Clearly)Routing Number (RTN)

                     

Required: Please indicate the correct account type Checking Savings

A VOIDED CHECK or letter on bank stationery confirming account title, account number, account type, and routing number is required. Deposit slips and bank statements will not be accepted. H&R Block Bank is not liable for problems or delays caused by inaccurate or incomplete information provided by you on this IRA Distribution form. Accordingly, we ask that you review the form again to ensure that it contains accurate information for your IRA Distribution request.

Withholding Election

Age 59 ½ or Older (referred to as Normal for Traditional IRA)

I elect to have 10 % Federal income withheld from my IRA distribution (by not selecting, you are opting out)

I elect to have a rate of  % withheld from my IRA distribution (must be 10% or greater)

Note: IRS regulations require that 10% federal tax withholding be taken from your distribution. We encourage you to consult your accountant or tax advisor regarding your IRA distribution. By not indicating a withholding election above then you are choosing to opt out of withholding. If you elect not to have federal income tax withheld, you are liable for payment of federal income tax on the taxable portion of your distribution. You may be subject to tax penalties under the estimated tax payment rules if your payments of estimated tax and withholding are not adequate.

Important State tax withholding information: We will withhold state tax in accordance with the respective state’s rules if, at the time of distribution, your address of record is within a mandatory withholding state and you have federal income tax withheld.

Required
X.
Account Owner Signature			Date
			Form 307 Rev. 6/2013
H&R Block Bank	A Federal Savings Bank		Member FDIC