RMD Financial Document

RMD DISTRIBUTION AUTHORIZATION

Account and Owner Information

Account Owner:

Social Security Number / Tax ID:    Account Number:

Traditional IRA    Roth IRA    SEP IRA    SIMPLE IRA

401(k)    403(b)    Other:

Required Minimum Distribution Details

Tax Year for RMD:    Date of Birth (Owner):

Full Required Minimum Distribution as calculated by custodian
Specified dollar amount:
Periodic payments (specify frequency and start date)
Frequency:    Start Date:

RMD Calculation Method

Select method for life expectancy and RMD calculation (custodian will apply method selected below unless state or plan rules require otherwise):

Uniform Lifetime Table (standard)
Joint Life Expectancy Table (spouse beneficiary). Spouse Date of Birth:
Custodian calculation based on plan provisions or trustee determination

Tax Withholding Elections

Federal income tax withholding: By default federal income tax may be withheld from distributions. Indicate your election below. If no election is made, the custodian will withhold in accordance with applicable statutory requirements.

Withhold federal income tax at the following percentage:
Do not withhold federal income tax

Elect state income tax withholding at:    State of residence for withholding purposes:

Backup withholding: I certify under penalties of perjury that I am not subject to backup withholding or I am otherwise required to have backup withholding applied as indicated.

Payment Instructions

Payment method (select one):

Mail check to account owner at address on file
Mail check to alternate address:
ACH deposit to bank account (provide details below)

Representations, Authorizations, and Indemnification

By signing below I certify that I am the lawful owner or authorized representative of the account identified above, that the information provided on this form is true and correct, and that I am eligible under the terms of the plan and governing documents to receive the requested distribution. I authorize the custodian to process the distribution in accordance with this instruction and to rely on any forms and identifications provided by me.

I acknowledge that distributions may be taxable and subject to penalties under applicable law. I understand that the custodian does not provide tax advice and that I am responsible for determining the tax consequences of this distribution. To the fullest extent permitted by law, I agree to indemnify and hold harmless the custodian, its officers and agents from and against any loss, liability or expense arising from acting on this instruction in good faith and without gross negligence.

Authorization: I have read and accept the terms above and authorize this distribution.

Certification

I certify under penalty of perjury that the taxpayer identification number provided on this form is correct, that I am not subject to backup withholding unless indicated, and that I am a U.S. person (including a U.S. resident alien) for tax purposes unless I have completed an appropriate withholding exemption form as required by the custodian's procedures.

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