Millennium Trust Distribution Form – Fill Out and Use This PDF

2001 Spring Road, Suite 700 Oak Brook, IL 60523 800.618.6177 Individual Service Team 866.388.5464 Institutional Service Team 800.560.1288 Advisor Service Team 630.472.5392 Fax distributions@mtrustcompany.com

To complete this form, you will need your:

IRA DISTRIBUTION REQUEST

Please select one

account type.

Traditional IRA

Roth IRA

Inherited Traditional IRA

SIMPLE IRA

SEP IRA

Inherited Roth IRA

Please submit an Address Change Request form (#OPR-009) if box is checked.

Check here if requesting a change of address with Millennium Trust Company (“Millennium”). To verify the current address on file, refer to your most recent Millennium statement or contact our client service department.

Note: If you have a distribution pending, your distribution may be subject to a 10 business day hold after Millennium Trust completes the processing of your Address Change Request.

Please continue to page two to complete this form.

Please select only

ONE reason for your

distribution from Section 1, 2, or 3.

1.From a Traditional IRA, Rollover IRA, or Inherited Traditional IRA only:

Normal Distribution. - Select if the taxpayer is age 59½ or older.

Early (Premature) Distribution. - Select if the taxpayer has not reached age 59½.

∙Distributions before the age 59½ may be subject to ordinary income tax and may also be subject to a 10% federal penalty tax unless you meet an IRS exception.

∙A distribution from a SIMPLE IRA taken within two years of the date the first contribution was made may be subject to a 25% penalty tax unless you meet an IRS exception.

Note: If you believe an exception may apply to the early withdrawal penalty, you should consult your tax advisor to determine if you need to submit IRS Form 5329 to the IRS.

Disability Distribution. - Select if distribution is due to permanent disability within meaning of IRS Code Sec 72(m)(7). Consult your tax advisor for assistance. (Attach Physician’s Statement.)

Distribution from an Inherited Traditional IRA. (Certified Copy of Death Certificate required if not already on file with Millennium.)

2.From a Roth IRA or Inherited Roth IRA only:

 Qualified Distribution from a Roth IRA. - Select if the five-year holding period has been completed and the taxpayer has reached age 59½, if the taxpayer is disabled (attach Physician’s Statement), or for a distribution from an Inherited Roth IRA. (Certified Copy of Death

Certificate required if not already on file with Millennium.)

Roth IRA Distribution, Exception applies. Consult your tax advisor for assistance. Select if it is not known if the five-year holding period has been completed and the taxpayer has reached age 59½, if the taxpayer is disabled (attach Physician’s Statement), or for a distribution from an Inherited Roth IRA. (Certified Copy of Death Certificate required if not already on file with

Millennium.)

Early Distribution from a Roth IRA. - Select if the taxpayer has not reached age 59½.

An additional fee may

apply if check for rollover funds are returned to Millennium or if tax reporting corrections are necessary.

3.Direct Rollover to a Employer Sponsored Qualified Plan - For direct Trustee to Trustee IRA transfers, contact the receiving institution to request a transfer. This form will not facilitate a direct Trustee to Trustee transfer process of an IRA.

Complete information below and skip Section E. NOTE: It is your obligation to ensure that the Qualified Plan named below will accept the rollover of your benefit payment. Payment Delivery via check only. (If the mailing address below is different than the address on record with Millennium

Trust then a Notary is required - See Page 5.)

Check Payable To:

Qualified Plan Name:

Qualified Plan No.:

City:

State:

Zip:

Please select one.

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Total distribution of my entire account and close account. (All assets will be liquidated.)

Partial distribution of $		. (Tell us what to sell in Section C1 if insufficient cash.)

Systematic Payment (Please complete Section D.)

Liquidation or Re-

Registration fees may

apply.

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Millennium will request funds be sent by check unless otherwise indicated.

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

Check (Upon receipt of funds, a 5 business day hold is required before funds are disbursed.)

Wire Transfer (Additional third-party fees may apply.)

Millennium is not responsible if the asset has its own required delivery method.

If cash funds are not available at the time of distribution, your check or ACH will not be issued as scheduled.

Only complete this section if you checked the “Systematic Payment” box in Section C. This distribution form needs to be received by the 1st of the month in which the first systematic payment is to begin. Please note that checks received are subject to a 5 day hold and may impact the availability of dollars to fund this recurring distribution. Systematic payments, including your tax withholding election, will continue until Millennium receives written direction to cancel.

Note: Systematic payments with a set dollar amount will be discontinued if there are three consecutive failed attempts due to insufficient cash.

New/Set Up

Change of Instructions (Complete entire form.)

Amount of systematic payment: $

Starting Month:		Day Preferred:		5th		15th

(If Day is not selected, Millennium will default to payments being issued on the 15th of the month.)

Frequency of future payments:			Monthly
			Quarterly

Please select your

delivery method from

the following four options. If a check is selected, it will be sent to you via U.S. Mail

Standard NACHA

Operating Rules apply.

Any taxable distribution request over $200,000 will be processed as a Direct Deposit to Bank (ACH) or Wire.

 Mail a check to the address of record.

Mail a check to the following address. (Notary Required - See Page 5.)

Payee:

Address:

City:		State:		Zip:

 Direct Deposit to Bank (ACH) - For distributions for $2,000 or more, please submit a voided check (starter checks are not acceptable) and provide the financial institution’s ACH instructions below.

Note: For accounts without checks, submit a preprinted deposit slip or a letter from the other financial institution, on letterhead and signed by an officer. This documentation must include the account title, account number, ABA routing number and account type. (Notary is required if funds are being sent to an account not registered in the name of the Account Owner.)

Wire funds - Not available for Systematic payments. Additional fees may apply.

Note: Account Owner may be contacted for further verification of the banking information provided. (Notary is required if funds are being sent to an account that is not registered in the name of the Account Owner.)

Please ensure the accuracy of your financial institution’s

Banking Information - Complete if you selected Direct Deposit to Bank (ACH) or Wire funds above. If

banking information is entered but a selection is not made, funds will be sent via Direct Deposit (ACH).

ACH/wire instructions.

An additional fee will be charged if a ACH/wire is rejected due to the incorrect instructions.

Bank Name:

Bank Address:

City:

ABA Routing No.:

Name on Bank Account:

State:

Bank Account No.:

Zip:

Please select one of these options. If no selection is made, taxes will automatically be withheld from the distribution(s) at a rate of 10%.

Federal Withholding Election - Internal Revenue Service (“IRS”) regulations require this notice to be given to you each time you request a distribution from your Account.

The distribution(s) you receive from your Account are subject to Federal Income Tax withholding, unless you elect not to have withholding apply. You may be liable for payment of any Federal Income Tax due on distribution(s) from your Account, regardless of whether or not you elect to have taxes withheld. In addition, if your payments of estimated tax and withholding are not adequate, you may be subject to tax penalties under estimated tax payment rules. You are urged to consult your tax advisor with respect to your election of Federal Income Tax withholding.

 I DO NOT want Federal Income Tax withheld from my distribution(s).

Withhold 10% for Federal Income Taxes from my distribution(s).

	Withhold			% (minimum 10%).
	Withhold $			for Federal Income Taxes from my distribution(s). (minimum 10%)

Please select one of these options. If no selection is made, we will withhold your state’s requirement from your distribution(s).

State Withholding Election Continued

State income tax withholding is based on the state of residence, federal income tax withholding election and account type. Millennium may not be able to process a distribution without state income tax withholding if the state requires it. Note: We will only withhold state income tax for the states listed on the State

Income Tax Withholding Information sheet located in the back of this form.

I declare my permanent state of residence is:

and that my election should

reflect the requirements of that state. If a permanent state of residence is not noted, we will default to the state of residence listed on file at Millennium.

 I DO NOT want state income tax withheld from my distribution(s).

Withhold my state’s minimum requirement. (Only applicable if a minimum tax rate exists for your state.)

	Withhold this amount:		% or $		.

We will withhold at least your state’s minimum requirement as listed on the State Income Tax Withholding Information sheet.

Applicable account distribution and/or closing fees will be assessed and if this distribution brings your account balance to zero, your account will be closed.

I authorize and direct Millennium as IRA Custodian to make the above withdrawal. I understand that I am responsible for all federal, state and local taxes, as well as estimated tax payments and penalties, if any. I understand that IRS regulations require tax withholdings at 10% for distributions from non-Roth IRAs unless I elect otherwise.

I understand that distributions from a Roth IRA that are attributable to either converted amounts, retirement plan rollover basis or earnings may be taxed as ordinary income and subject to a 10% early withdrawal penalty unless certain requirements are met.

I understand that all non-Roth IRA distributions will generally be taxed as ordinary income and may be subject to a 10% early withdrawal penalty if taken before age 59½. If I am over age 70½, I accept full responsibility for withdrawing from my Traditional, Rollover or SEP IRA the minimum required distribution required by the Internal Revenue Code.

I certify that all of the information I have provided on this form is correct. I have consulted my tax advisor concerning the taxable effect of this withdrawal; and I certify that Millennium Trust has not provided me with tax, investment or legal advice. I indemnify Millennium Trust Company, LLC, its affiliates, successors, and assigns, from any and all liability arising from this withdrawal.

INotary Public

A Notary Public is

required if requesting funds over $10,000 that will be sent to an address other than the account owner’s current address of record, an account not held in the name of the account owner, or if the proceeds will be sent to an ex-spouse due to divorce. Forms received without the required Notary will be rejected.

Sworn to and subscribed before me on:	Place Notary Seal Here
________________, 20______.
Notary Public: _______________________________________
My Commission Expires: ______________________________

All requests requiring a Notary or certified legal documentation must be received by mail unless uploaded

to Millennium through a secured portal.

2001 Spring Road, Suite 700

Oak Brook, IL 60523

As of 01/01/19

STATE INCOME TAX WITHHOLDING INFORMATION FOR IRAS

State of	State income tax withholding
residence	information
AZ, CO, D.C.,	State income tax will be withheld ONLY
MD, NJ, NY, VA	if you instruct us to withhold it whether
	or not you elect to have federal income
	tax withheld. See below for exception.
	D.C.: Required if a total distribution is
	elected or taken by default
KS, MA, ME,	State income tax withholding is
NE, OK, VT	required when federal withholding is
	elected or taken by default.
CA, DE, OR	State income tax withholding is
	required when federal withholding is
	elected or taken by default, unless you
	instruct us not to withhold state income
	taxes.
AR, CT, IA, MI,	State income tax withholding is
NC	required. However, if you believe you
	will not have a balance due on your
	state income tax return, you may elect
	not to have state income tax withheld
	by submitting your states W-4P form.
	Consult your tax advisor for guidance
	on all of the limitations/restrictions for
	state tax withholding.

OPR-050

State of	Minimum state income tax rate is at least
residence
AR	3% of the gross distribution amount
CA	10% of the federal withholding amount when
	elected
CT	6.99% of the gross distribution amount
D.C.	8.95% of the gross total distribution amount
DE, IA, KS, ME,	5% of the gross distribution amount
NE, OK
MA	5.05% of the gross distribution amount
MI	4.25% of the gross distribution amount
NC	4% of the gross distribution amount
OR	8% of the gross distribution amount
VT	30% of the federal withholding amount when
	elected
AZ, CO, MD, NJ,	There is no minimum tax rate. You may provide
NY, VA	any amount.
	03-19