Mt Bank Beneficiary – Fill Out and Use

q Traditional IRA

q Roth IRA

q SEP IRA

q Simple IRA

If you want to designate different beneiciaries for different account types, please complete a separate form for each.

SECTION 2: Investor Information

Account Number

Owner’s Name (LAST, FIRST, MIDDLE INITIAL)

Owner’s Social Security Number

Date of Birth (MM/DD/YY)

Address of Residence - P.O. Box is not accepted

City, State, Zip Code

Mailing Address - If different from above (P.O. Boxes accepted)

City, State, Zip Code
(	)	(	)
Day Phone			Evening Phone

E-mail Address

SECTION 3: Designation/Change of Beneiciary(ies)

The following individual(s) or entity(ies) shall be my primary and/or contingent beneiciary(ies). If neither primary nor contingent is indicated, the individual or entity will be deemed to be a primary beneiciary. If more than one primary beneiciary is designated and no distribution percentages are indicated, the beneiciaries will be deemed to own equal share percentages in the IRA. Multiple contingent beneiciaries with no share percentage indicated will also be deemed to share equally.

If any primary or contingent beneiciary dies before I do, his or her interest and the interest of his or her heirs shall terminate completely, and the percentage share of any remaining beneiciary(ies) shall be increased on a pro rata basis. If no primary beneiciary(ies) survives me, the contingent beneiciary(ies) shall acquire the designated share of my IRA.

q Primary	q Contingent
Beneiciary’s Name (LAST, FIRST, MIDDLE INITIAL)
Beneiciary’s Social Security Number		Date of Birth (MM/DD/YY)
Address of Residence - P.O. Box is not accepted
City, State, Zip Code

Mailing Address - If different from above (P.O. Boxes accepted)

City, State, Zip Code
(	)	(	)
Day Phone			Evening Phone
E-mail Address
			%
Relationship			Percentage
q Primary		q Contingent
Beneiciary’s Name (LAST, FIRST, MIDDLE INITIAL)
Beneiciary’s Social Security Number			Date of Birth (MM/DD/YY)

Address of Residence - P.O. Box is not accepted

City, State, Zip Code

Mailing Address - If different from above (P.O. Boxes accepted)

City, State, Zip Code
(	)	(	)
Day Phone			Evening Phone
E-mail Address
			%
Relationship			Percentage
q Primary		q Contingent
Beneiciary’s Name (LAST, FIRST, MIDDLE INITIAL)
Beneiciary’s Social Security Number			Date of Birth (MM/DD/YY)

Address of Residence - P.O. Box is not accepted

City, State, Zip Code

Mailing Address - If different from above (P.O. Boxes accepted)

City, State, Zip Code

SECTION 3: Designation/Change of Beneiciary(ies)

(continued)

(	)	(	)
Day Phone			Evening Phone
E-mail Address
			%
Relationship			Percentage
q Primary		q Contingent
Beneiciary’s Name (LAST, FIRST, MIDDLE INITIAL)
Beneiciary’s Social Security Number			Date of Birth (MM/DD/YY)

Address of Residence - P.O. Box is not accepted

City, State, Zip Code

Mailing Address - If different from above (P.O. Boxes accepted)

City, State, Zip Code
(	)	(	)
Day Phone			Evening Phone
E-mail Address
			%
Relationship			Percentage

Spousal Consent:

This section should be reviewed if either the trust or the residence of the IRA holder is located in a community or marital property state and the IRA holder is married. Due to the important tax consequences of giving up one’s community property interest, individuals signing this section should consult with a competent tax or legal advisor.

CURRENT MARITAL STATUS

qI Am Not Married – I understand that if I become married in the future, I must complete a new IRA Designation/Change Of Beneiciary form.

qI Am Married – I understand that if I choose to designate a primary beneiciary other than my spouse, my spouse must sign below.

CONSENT OF SPOUSE

I am the spouse of the above-named IRA holder. I acknowledge that I have received a fair and reasonable disclosure of my spouse’s property and inancial obligations. Due to the important tax consequences of giving up my interest in this IRA, I have been advised to see a tax professional.

I hereby give the IRA holder any interest I have in the Fund or property deposited in this IRA and consent to the beneiciary designation(s) indicated above. I assume full responsibility for any adverse consequences that may result. No tax or legal advice was given to me by the Custodian.

Signature of Spouse	Date (MM/DD/YY)
Signature of Witness	Date (MM/DD/YY)

SECTION 4: Trust Beneiciary(ies)

Complete this section if a trust is one of your primary beneiciaries. Consult your attorney regarding this designation.

Name of Trust

Street or P.O. Box

City, State, Zip Code

Percentage %

Date of Trust

Trust’s Tax Identiication Number

SECTION 5: Signature

I hereby revoke all previous beneiciary designations for my Whitebox Mutual Funds. I understand that I may change my beneiciary at any time and that the change is effective when received in writing and accepted by Whitebox Mutual Funds.

Owner’s Signature	Date (MM/DD/YY)
Please mail completed form to:
Mailing Address	Overnight Address
Whitebox Mutual Funds	Whitebox Mutual Funds
P.O. Box 13393	1290 Broadway, Suite 1100
Denver, CO 80201	Denver, CO 80203

If you have any questions, please contact an Investor Service Representative at 1-855-296-2866 or visit www.whiteboxmutualfunds.com.