Ira Contribution Instructions - First Bankers Trust Services
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IRA Contribution Instructions
for Traditional, Roth, and SIMPLE IRAs
IRA OWNER INFORMATION
NAME, ADDRESS, CITY, STATE, AND ZIP
IRA ACCOUNT (PLAN) NUMBER
SOCIAL SECURITY NUMBER
DATE OF BIRTH
DAYTIME PHONE NUMBER
TRADITIONAL IRA CONTRIBUTION
(See Additional Information included with this form.)
INVESTMENT NUMBER
AMOUNT
CONTRIBUTION DATE
TAX YEAR
$
l
l
Regular (including Catch-Up)
Rollover/Direct Rollover from an Eligible Retirement Plan
CONTRIBUTION TYPE:
l
l
Simplified Employee Pension (SEP) Plan
Qualified Reservist/Designated Disaster Distribution Repayment*
l
l
Recharacterization
Disaster/Combat Zone Postponed Contribution*
l
Rollover
*Reason Code (if applicable)
l
Transfer
ROTH IRA CONTRIBUTION
(See Additional Information included with this form.)
TAX YEAR OF FIRST ROTH IRA
INVESTMENT NUMBER
AMOUNT
CONTRIBUTION DATE
TAX YEAR
CONTRIBUTION/CONVERSION
$
l
l
Regular (including Catch-Up)
Rollover/Direct Rollover from an Eligible Retirement Plan
CONTRIBUTION TYPE:
l
l
Rollover
Rollover/Direct Rollover from a Designated Roth Account
l
l
Transfer
Qualified Reservist/Designated Disaster Distribution Repayment*
l
l
Recharacterization
Disaster/Combat Zone Postponed Contribution*
l
Conversion
*Reason Code (if applicable)
SIMPLE IRA CONTRIBUTION
(See Additional Information included with this form.)
INVESTMENT NUMBER
AMOUNT
CONTRIBUTION DATE
TAX YEAR
INITIAL CONTRIBUTION DATE
$
l
l
Employer Contribution
Rollover from a SIMPLE IRA
CONTRIBUTION TYPE:
l
l
Recharacterization
Transfer from a SIMPLE IRA
EMPLOYER INFORMATION
(For SEP or SIMPLE contributions.)
NAME, ADDRESS, CITY, STATE, AND ZIP
TAXPAYER IDENTIFICATION NUMBER
DAYTIME PHONE NUMBER
SIGNATURES
I certify that I am the IRA owner, employer, or individual legally authorized to complete this form. I certify the accuracy of the information set
forth in this form, and I authorize this transaction. I certify that this contribution is eligible for deposit, and I assume full responsibility for
determining my eligibility and for ensuring the eligibility of the contribution. My designation of the tax year for the contribution, and any election
to treat a contribution as a rollover or recharacterization, is irrevocable. I indemnify and agree to hold the custodian/trustee harmless from any
resulting liabilities. I acknowledge that the custodian/trustee cannot provide, and has not provided, me with tax or legal advice. I have been
advised to seek the guidance of a tax or legal professional.
Signature of IRA Owner/Employer
Date
Signature of Custodian/Trustee
Date
IRA Contribution Instructions for Traditional, Roth, and SIMPLE IRAs
IRACMBCONLAZ 1/1/2011
Bankers Systems
*
Wolters Kluwer Financial Services
1998, 2011
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