Individual Retirement Account (Ira) Distribution Request Form (Page 2 of 4) in pdf

B. QUALIFIED DISTRIBUTION FROM A ROTH IRA

This Roth IRA distribution satisfies the 5-year holding period requirement:

Yes

(If “No”, proceed to Section C)

The distribution is being made for the following reason (check one):

1. You are age 59½ or older.

2. Death/Beneficiary liquidation - If you are a beneficiary, contact Shareholder Services regarding additional document requirements.

3. Permanent disability - You certify that you are disabled within the meaning of section 72(m)(7) of the Internal Revenue Code.*

Note: Distributions not meeting the 5-year required period and for all other reasons not listed above are considered non-qualified.

C. NON-QUALIFIED DISTRIBUTION FROM A ROTH IRA

The distribution is being made for the following reason (check one):

1. Normal distribution (prior to the 5-year holding requirement) - 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 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. 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.

IV. EXCESS CONTRIBUTION ELECTION

Amount of excess: $_________________________ Tax year for which excess contribution was made:_____________ Date Deposited:______________

Earnings will be removed with the excess contribution if corrected before your federal income tax-return due date (including extensions), pursuant to Internal

Revenue Code Section 408(d)(4) and Internal Revenue Service ("IRS") Publication 590. You may be subject to an IRS penalty of 6% for each year the excess remains in

the account. In addition, the IRS may impose a 10% early distribution penalty on the earnings, if you are under age 59½. You will receive IRS Form 1099-R for the year

in which the excess distribution takes place (not for the year in which the excess contribution was made). Consult IRS Publication 590 for more information pertaining

to excess contributions. If you are subject to a federal penalty tax due to an excess contribution, you must file IRS Form 5329.

For the purpose of the excess contribution, we will calculate the net income attributable ("NIA") to the contribution using the method provided in the IRS Final

Regulations for Earnings Calculation for Returned or Recharacterized Contributions. This method calculates the NIA based on the actual earnings and losses of the IRA

during the time it held the excess contribution. Please note that a negative NIA is permitted and, if applicable, will be deducted from the amount of the excess

contribution.

A. The excess is being corrected before your federal income tax-filing deadline (including extensions):

Remove excess plus/minus net income attributable. Distribute according to my instructions in Section VI (Mailing Instructions).

Remove excess plus/minus net income attributable. Re-deposit as a current year contribution (not to exceed annual IRA contribution limit).

B. The excess is being corrected after your federal income tax-filing deadline (including extensions). Earnings on the excess contribution will remain in the

account.

Remove excess and distribute according to my instructions in Section VI (Mailing Instructions).

Remove excess and re-deposit as a current year contribution (not to exceed annual IRA contribution limit).

C. Redesignating an excess contribution to a later tax year. Please consult a tax advisor to review your specific situation and to determine your best course of

action. If you should decide to carry over the excess contribution to a later year, DO NOT RETURN THIS FORM.

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