Fillable Brokerage Account Application, Roth Ira Forms (Page 4 of 4) in pdf

Roth IRA

(Individual Retirement Account)

IRA ACCOUNTHOLDER

Name

First

Middle

Last

Home Address

Street

City

State

ZIP

Home Phone

Work Phone

Social Security/Tax ID Number

Date of Birth

ext.

DESIGNATION OF BENEFICIARY(IES)

In the event of my death, the following primary beneficiary(ies) will own the designated share percentage of assets in the IRA as indicated below. If more than one primary

beneficiary is designated and no share percentages are indicated, the designated primary beneficiaries will be deemed to own equal share percentages of the total assets in the

IRA. If no primary beneficiary(ies) survives me, the following contingent beneficiary(ies) will own the designated share percentage of assets in the IRA as indicated below. If more

than one contingent beneficiary is designated and no share percentages are indicated, the designated contingent beneficiaries will be deemed to own equal share percentages of

the total assets in the IRA.

If a beneficiary is not designated as primary or contingent, said beneficiary will be deemed a primary beneficiary. If a beneficiary(ies), in writing, disclaims interest in the IRA,

Scottrade will treat the disclaiming beneficiary(ies) as though the disclaiming beneficiary(ies) predeceased me. If a primary or contingent beneficiary predeceases me, the deceased

beneficiary's interest in the IRA terminates completely and the percentage share of any remaining primary or contingent beneficiary(ies), as applicable, shall be increased on a pro

rata basis. In the event that all of the beneficiaries designated below predecease me, I have not designated a beneficiary(ies), or I subsequently revoke my beneficiary designation,

my estate will be the beneficiary.

I understand that I may change or revoke this designation by completing and delivering to Scottrade the IRA Beneficiary Update form. Scottrade, in its sole and absolute discretion,

may reject any beneficiary document received after my death. Scottrade has the right not to distribute to one or more beneficiaries if there is a dispute related to the IRA until

additional information or documentation requested is received and accepted.

Social Security/

U.S.

Relationship to

Primary or

Beneficiary Name

Address

Date of Birth

Tax ID Number

Citizen

Accountholder

Contingent

Yes

Primary

Contingent

Primary

Yes

Contingent

Yes

Primary

Contingent

Yes

Primary

Contingent

Primary

Yes

Contingent

SPOUSAL CONSENT

Spouse of the Accountholder must read and sign below if the Accountholder's trust or residence is

Accountholder is not married

Accountholder is married -

located in a community or marital property state and the spouse is not the 100% primary beneficiary.

Due to the important tax consequences of giving up one's community property interest, a spouse signing this section should consult with a professional tax and/or

legal advisor.

I am the spouse of the above-named Accountholder and am familiar with the assets in the IRA. I hereby waive all rights and interest I have in the IRA following the death of the

Accountholder, consent to the beneficiary designation(s) indicated above, and assume full responsibility for any adverse consequences that may result. I agree not to make any

claim against Scottrade or the designated beneficiaries in connection with the IRA.

Spouse's Printed Name

Spouse's Signature

Date

SIGNATURES

By signing below, I affirm that: I understand the eligibility requirements for the type of IRA deposit I am making and I do qualify to make the deposit. I have received a copy of the

Application, the 5305-A Plan Agreement, the Financial Disclosure and the Disclosure Statement. I understand that the terms and conditions which apply to this IRA are contained in

this Application and the Plan Agreement, and I agree to be bound by those terms and conditions. Within seven (7) days from the date I open this IRA, I may revoke it without

penalty by mailing or delivering a written notice to Scottrade. I assume complete responsibility for:

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

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

3. The tax consequences of any contribution (including rollover contributions) and distributions.

I expressly certify that I take complete responsibility for the investments I choose to buy, sell, and/or hold in my IRA. I further certify that Scottrade is released from any and all

liability regarding the performance of any investment choice I make. Scottrade has provided no tax or legal advice to me regarding my IRA.

*SF2362*

Accountholder Signature

Date

SF2362/9-15

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