Ira Distribution Request

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IRA distribution request
Introduction
Instructions
Questions about this form?
800-225-5291
Please use this form for John Hancock custodial Traditional IRA, Roth IRA, or Coverdell ESA accounts. This
form allows you to request an immediate distribution or a future systematic payment. Do not use this form for
SIMPLE IRA or 403(b)(7) distributions. Instead, use the SIMPLE IRA distribution request form or the 403(b)(7)
Contact us:
distribution request form. Please print in all capital letters and use black ink.
800-225-5291
See the end of this document for
return instructions
1. Type of account (check one)
Traditional IRA
Roth IRA
Coverdell Education Savings Account (ESA)
SEP/SARSEP
Note: For SIMPLE IRA distributions, use the SIMPLE IRA distribution form. For 403(b)(7) plan distributions, use the 403(b)(7) distribution request form.
2. Your information
Plan name (required for SEP/SARSEP only)
Name (First)
(MI)
(Last)
Date of birth (MM/DD/YYYY)
Phone number
Fund name or number (required)
Account number (required)
3. Type of distribution (check one)
Note: For distributions from multiple accounts, please use a separate form for each account or attach an itemized breakdown listing the fund, account, and amount
to be distributed from each account.
Coverdell ESA distribution: I am the responsible individual or designated beneficiary of the ESA and acknowledge the tax consequences.
Normal: I have attained or am over the age of 59
/
. (Your distributions must begin by April 1 of the year following your attainment of age 70
/
.)
1
1
2
2
Premature: I am under the age of 59
1
/
and I am aware that this is a premature distribution and may be subject to IRS penalties. *
2
Substantially equal periodic payments: I intend to receive substantially equal periodic payments (not less frequently than annually), made for my life
(or the life expectancy) or the joint lives (or joint life expectancy) of myself and my beneficiary. If the payment amount has been determined, complete the
“Systematic withdrawal payments” in Part B of Section 4; otherwise, complete the “Life expectancy payments” in Part B of Section 4.
Death: I am the beneficiary or inherited owner of this account. A copy of the death certificate and a completed IRA adoption agreement are attached. Also
attached, if required, is a tax waiver from the deceased’s state of residence. I understand this distribution method will generally involve a change of ownership.
Disability: I am unable to engage in any substantial gainful activity by reason of a medically determinable physical or mental impairment, and my condition is
expected to result in death or to be of long, continued, and indefinite duration. (A statement on a doctor’s letterhead is required.)
Excess contribution: Remove my excess contribution of $
made for the
tax year.
Please check one.
Issue the check to me, including any net income earned on the excess amount.
Remove the excess monies and interest and reapply them as a:
Current year contribution
Prior year contribution (January 1 through April 15 only)
Remove the excess monies and interest. I have filed an extension with the IRS. Reapply them as a current or prior year contribution.
For SEPs and SARSEPs only:
Employee
Employer
ROTH IRA only:
This distribution is being taken within the first five years of establishment.
* If you are under 59
/
, you will be subject to a 10% early withdrawal penalty unless you meet an exception under the Internal Revenue Code. In order to claim an
1
2
exception, you must file IRS Form 5329. Visit the IRS website at irs.gov for more details.
IRADRFM (2/17)
PAGE 1 OF 3

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