Individual Retirement Account (Ira) Distribution Request Form

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THIRD AVENUE FUNDS INDIVIDUAL RETIREMENT ACCOUNT (IRA)
DISTRIBUTION REQUEST FORM
This form is not intended for required minimum distributions, trustee to trustee transfers, recharacterizations, or conversion requests.
I. PARTICIPANT INFORMATION
– Please print
Name:
Daytime Telephone: (
)
Address:
City:
State:
Zip Code:
Social Security Number:
Date of Birth:
Account Number:
Complete the following if you are a beneficiary requesting a full liquidation of the inherited proceeds.
Beneficiary Name:
Daytime Telephone: (
)
Social Security Number:
Date of Birth:
II. TYPE OF ACCOUNT
Traditional / Rollover IRA
SEP IRA
Roth IRA - (Proceed to Section III - B or C)
Note: For trustee to trustee transfers, please complete the appropriate receiving custodian’s trustee to trustee transfer form. This form is not intended to facilitate a
beneficiary/inherited IRA transfer due to death. For revocations, refer to the Traditional and Roth Individual Retirement Account (IRA) Combined Disclosure
Statement for instructions and information regarding your revocation rights. All required documentation must be received in good order before the distribution
request can be honored. All legal documents must be certified and a Medallion Signature Guarantee may be required. Please see the Participant Authorization
Section for an explanation of the Medallion Signature Guarantee.
III. REASON FOR DISTRIBUTION
A. FROM A TRADITIONAL, ROLLOVER OR SEP IRA
The distribution is being made for the following reason (check one):
1. Normal distribution - You are age 59½ or older.
2. Early (premature) distribution - You are under age 59½, including distributions due to medical expenses, health insurance premiums, higher education
expenses, first time homebuyer expenses, or other reasons.
3. Substantially equal periodic payments within the meaning of section 72(t) of the Internal Revenue Code.
4. Death/Beneficiary liquidation - If you are a beneficiary, contact Shareholder Services regarding additional document requirements.
5. Permanent disability - You certify that you are disabled within the meaning of section 72(m)(7) of the Internal Revenue Code.*
6. Transfer incident due to divorce or legal separation - Contact Shareholder Services regarding additional document requirements.
7. Removal of excess - You must complete Section IV (Excess Contribution Election) in its entirety.
8. Direct rollover to a Qualified Plan, 401(k), TSP or 403(b) - You are certifying that the receiving custodian will accept the IRA assets issued.
9. Qualified Reservist Distribution
* For purposes of section 72(m)(7), an individual shall be considered to be disabled if he is unable to engage in any substantial gainful activity by reason of any
medically determinable physical or mental impairment which can be expected to result in death or to be of long-continued and indefinite duration.
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