Fillable Brokerage Account Application, Simple Individual Retirement Account Forms (Page 4 of 4) in pdf

*SF2039*

SIMPLE Individual Retirement Account

SF2039/8-15

PARTICIPANT’S NAME AND ADDRESS

SIMPLE IRA CUSTODIAN’S NAME, ADDRESS AND PHONE

Scottrade, Inc.

P.O. Box 31759

St. Louis, MO 63131-0759

S IMPLE IRA

Social Security Number

Home Phone

Business Phone

Employer’s Plan Name

Account Identification

Date of Birth

E-mail Address

Employer’s Name, Address and Phone

CONTRIBUTION INFORMATION

Contribution Date

Contribution Amount

Check here if this is a transfer SIM

PLE IRA.

DESIGNATION OF BENEFICIARY(IES)

The following individual(s) or entity(ies) will be my primary and/or contingent beneficiary(ies). If neither primary nor contingent is indicated, the individual or

entity will be deemed to be a primary beneficiary. If more than one primary beneficiary is designated and no distribution percentages are indicated, the

beneficiaries will be deemed to own equal share percentages in the SIMPLE IRA. Multiple contingent beneficiaries with no share percentage indicated will also

be deemed to share equally. If any primary or contingent beneficiary dies before I do, his or her interest and the interest of his or her heirs will terminate

completely, and the percentage share of any remaining beneficiary(ies) will be increased on a pro rata basis. If no primary beneficiary(ies) survives me, the

contingent beneficiary(ies) will acquire the designated share of my SIMPLE IRA. If no beneficiaries are named, my estate will be my beneficiary. I understand that I

may change or add beneficiaries at any time by completing and delivering the proper form to the trustee or custodian. The trustee or custodian has provided no tax or

legal advice to me regarding my beneficiary designations.

I elect not to designate beneficiaries at this time and understand that I may designate beneficiaries at a later date.

Social Security

Primary or

No.

Beneficiary’s Name and Address

Date of Birth

Relationship

Share %

Number

Contingent

Primary

Contingent

Primary

Contingent

Primary

Contingent

Primary

Contingent

SPOUSAL CONSENT

SIGNATURES

Important: Please read before signing.

This section should be reviewed if either the trust or the residence of the

Participant is located in a community or marital property state and the

I understand the eligibility requirements for the SIMPLE IRA and I state that I

Participant is married. Due to the important tax consequences of giving

do qualify to establish a SIMPLE IRA. I have received a copy of the

up one's community property interest, individuals signing this section

Application, the 5305-SA Plan Agreement, the Financial Disclosure and the

should consult with a competent tax or legal advisor.

Disclosure Statement. I understand that the terms and conditions which

CURRENT MARITAL STATUS

apply to this SIMPLE IRA are contained in this application and the Plan

I Am Not Married – I understand that if I become married in the future, I

Agreement. I agree to be bound by those terms and conditions. Within seven

(7) days from the date I open this SIMPLE IRA, I may revoke it without

must complete a new SIMPLE IRA Designation Of Beneficiary form.

penalty by mailing or delivering a written notice to the Custodian.

I Am Married

– I understand that if I choose to designate a primary

beneficiary other than my spouse, my spouse must sign below.

I assume complete responsibility for:

1. Determining that I am eligible for a SIMPLE IRA each year I make an

CONSENT OF SPOUSE

elective deferral.

I am the spouse of the above-named Participant. I acknowledge that I have

2. Ensuring that all contributions I make are within the limits set forth by

received a fair and reasonable disclosure of my spouse's property and

the tax laws.

financial obligations. Due to the important tax consequences of giving up my

The tax consequences of any contribution (including rollover

interest in this SIMPLE IRA, I have been advised to see a tax professional.

contributions) and distributions.

I hereby give the Participant any interest I have in the funds or property

deposited in this SIMPLE IRA and consent to the beneficiary 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.

_______________________________________

__________________

(Participant)

(Date)

________________________________________

__________________

_______________________________________

__________________

(Signature of Spouse)

(Date)

(Authorized Signature of Custodian)

(Date)

Page 3 of 3

(Rev. 5/2012)

Brokerage Account Application, Simple Individual Retirement Account Forms Page 4

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