Ira Distribution Request Form - Greenspring Fund (Page 3 of 3) in pdf

Bank Information



A dd Bank Information (attach voided check)



M y existing bank information is no longer valid.



Please attach a voided check or pre-printed deposit slip.

C hecking

S avings

(We are unable to draft or credit to your account via ACH if it is a mutual fund or pass-through (“further credit to”) account.)

Adding or changing bank information

53289

John Doe

may require a signature guarantee per

Jane Doe

the Fund’s prospectus.

123 Main St.

Anytown, USA 12345

Pay to the order of _____________________________________________________ $ _______________

____________________________________________________________________________DOLLARS

Memo___________________________

Signed_________________________________________

Tax Withholding Election

Federal taxes will automatically be withheld from distributions at the rate of 10%, unless you check one of the boxes below.

 D o not withhold taxes. I understand that I am responsible for payment of any federal or state taxes on my distribution(s).

 P lease withhold _________% (minimum 10%) from my distribution(s). State withholding may also apply.

For systematic distributions, your withholding election indicated above will remain in effect until you revoke or change your withholding

election, which you may do at any time.



Residents of Arkansas and California only: Please check if you wish to opt out of state withholding.

Signature

I, the undersigned, authorize and request that U.S. Bancorp Fund Services, LLC, make the above distribution(s) from the account listed in Section One. I certify

that all information in this distribution request is accurate, and I agree to hold the Fund, its advisors, and U.S. Bancorp Fund Services, LLC, any affiliate, and/or

directors, trustees, employees, and agents harmless for any actions taken as a result of the information that I have provided. The undersigned acknowledges that

it is his/her responsibility to properly calculate, report, and pay all taxes due with respect to the distribution(s) herein specified. I have been advised to consult my

tax advisor regarding any questions about this distribution request.

SIGNATURE OF IRA OWNER

CAPACITY, IF APPLICABLE*

DATE SIGNED

SIGNATURE GUARANTEE

DATE

Note to Financial Institution: Please verify that the surety limit of your signature guarantee is equal to or greater than the value of this transaction request.

*If someone other than the registered account owner is signing this request, we will require the capacity of the signer to process the transaction. Please provide one of the

following as the signer’s capacity: Administrator, Conservator, Guardian, Executor, Personal Representative, Appropriate Person by Small Estate Affidavit, Power of Attorney.

Your signature must be guaranteed if you are requesting any of the following:

• A distribution greater than the signature guarantee threshold per the Fund’s prospectus.

• Adding or changing banking instructions.

• A distribution to an address other than the address of record.

• A distribution to any address of record changed within the last 15 or 30 days per the Fund’s prospectus.

• A distribution made payable to a third party.

• A distribution to an account registered other than, or in addition to, the IRA holder (i.e. RMD being distributed to a Joint Tenant account).

If required, the signatures must be guaranteed by a bank, savings association, credit union, a member firm of a domestic stock exchange, or the Financial Industry Regulatory

Authority, that is an eligible guarantor institution. A notary public is NOT an acceptable guarantor.

02/2012

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