Fillable Inherited Ira Distribution Request Form (Page 2 of 3) in pdf

C.- 2. METHOD OF DISTRIBUTION FOR ROTH IRA ACCOUNTS ONLY

Rollover - I elect to roll over the IRA into my own IRA. (Spouse ONLY)

Total Distribution - I elect to receive the IRA balance in a single sum.

5 Year Payments - I elect to deplete the IRA balance by December 31st of the year containing the 5th anniversary

of the original IRA account holder’s death.

I elect to deplete the IRA balance by taking payments over my own life expectancy.

Life Expectancy Payments -

I elect to use the remaining life expectancy of the decedent using the age in the year of

death non-recalculated in subsequent years.

D. TAX WITHHOLDING ELECTION (Form w-4/OMB No. 1545-0074)

A. Federal Withholding

Federal Income Tax must be withheld from distributions unless the recipient elects not to have withholding apply (excluding qualified Roth IRA

distributions). You may elect out of this withholding by checking the appropriate box below. Even if you elect not to have Federal income tax

withheld, you are liable for the payment of Federal income tax on the taxable portion of your distribution. Penalties may be incurred under the

estimated tax rules if your withholding and/or estimated tax payments are not sufficient. We urge you to seek competent professional tax advice.

See next page of this form for additional Withholding Notice Information.

IF NO ELECTION IS MADE, SCOTTRADE MUST WITHHOLD TAXES AT THE REQUIRED FLAT 10% RATE

(EXCLUDING QUALIFIED ROTH IRA DISTRIBUTIONS).

I elect not to have Federal income tax withheld

Withhold Federal income tax at a rate of ________% (not less than 10%) from the amount withdrawn

Withhold Federal income tax in the amount of $__________ (not less than 10%) from the amount withdrawn*

*Flat dollar amount elections not available for periodic distributions.

B. State Withholding

State Income Tax may be required from your distribution. In some cases, you may elect not to have withholding, or your state’s requirement may be

mandatory. In other cases, state withholding is prohibited. While Scottrade makes every effort to obtain information about state tax laws from sources

believed to be reliable, Scottrade cannot guarantee the accuracy or timeliness of state tax withholding information because state tax laws are subject

to constant change and interpretation. We recommend you seek competent professional tax advice regarding your tax withholding elections. Refer to

the State Tax Withholding Information sheet for specific requirements regarding your state of residence.

IF YOU DO NOT MAKE AN ELECTION, SCOTTRADE WILL WITHHOLD AT THE MINIMUM RATE

BASED ON THE REQUIREMENTS FOR YOUR STATE OF RESIDENCY.

NOTE: STATE INCOME TAX IS VOLUNTARY FOR ROTH IRAs.

I declare my permanent state of residence is __________.

State

I elect not to have State income tax withheld

Withhold State income tax at a rate of ________ % (must be at least your state’s minimum) from the amount withdrawn

Withhold State income tax in the amount of $______________ (must be at least your state’s minimum)

E. PLEASE SIGN THIS SECTION - Required

I certify that I am the eligible beneficiary authorized to make these elections. I understand these elections are irrevocable as of the deadline for

making elections. (Scottrade, Inc. or any future Custodian can rely on these elections). I certify that all information provided by me is true and

accurate and I agree to abide by current rules and regulations. I further certify that Scottrade, Inc. has given no tax advice to me and that all

decisions regarding the election(s) are my own. I expressly assume the responsibility for any adverse consequence, which may arise from the

election(s), and I agree that Scottrade, Inc. shall in no way be responsible for those consequences.

DATE

BENEFICIARY SIGNATURE

FOR SCOTTRADE USE ONLY

_______________________

___________________________________________________________

__________________________

Received

Authorized Signature of Custodian

Date Completed

Page 2 of 3

SF2036/11-14

Inherited Ira Distribution Request Form Page 2

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