Ira/qualified Plan Distribution Request Form (Sample)
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4IRA/Qualified Plan Distribution Request Form
Do not complete this form if request is for a Required Minimum Distribution (RMD). If request is for a RMD, please
complete the Required Minimum Distribution Form.
Regular Mail: Buffalo Funds
Overnight Delivery: Buffalo Funds
c/o U.S. Bancorp Fund Services, LLC
c/o U.S. Bancorp Fund Services, LLC
PO Box 701
615 E. Michigan St., FL3
Milwaukee, WI 53201-0701
Milwaukee, WI 53202-5207
1 Account Information
NAME (AS IT APPEARS ON YOUR ACCOUNT REGISTRATION)
MUTUAL FUND NAME AND ACCOUNT NUMBER
XXX - XX -
ADDRESS
SOCIAL SECURITY NUMBER
CITY
DATE OF BIRTH
STATE
ZIP CODE
DAYTIME PHONE
Note: If the address listed above is different than the address currently listed in our records, we will change all accounts under your Social
Security number to reflect your new address. All future correspondence will be sent to the new address until you advise us otherwise.
Distributions to a new address will require a signature guarantee in Section 7 of this form.
2 Type of Distribution | Select One
I request a distribution from my Retirement Account. I understand that it is my responsibility to determine that amounts distributed
from my account are made in compliance with all Internal Revenue Service (IRS) regulations. I understand that a distribution fee may
apply per the Fund’s prospectus. We recommend that you consult with your professional tax advisor prior to requesting the distribution.
N ormal Distribution. I have reached age 59 ½.
Conversion to Roth IRA. Conversion from a Traditional, SEP,
or SIMPLE IRA. The deadline for a conversion is December 31st.
P remature Distribution. I am under age 59 ½. I understand
Conversions are not allowed from a SIMPLE IRA within two years of
that I may be responsible for paying a 10% premature withdrawal
the initial SIMPLE contribution. If you are 70 ½ years of age or older,
penalty in addition to normal income tax for an early withdrawal.
your Required Minimum Distribution (RMD) must be distributed prior
*To claim an exception from the premature distribution penalty, you
to the conversion.
should file IRS Form 5329.
Please distribute my current year RMD before the conversion.
I will satisfy my current year RMD from an IRA at another financial
72(t) Substantially Equal Periodic Payments. (under IRS
institution.
Code Section 72(t)(2)(A)(iv)). Please see your professional tax
advisor for guidance.
Recharacterization.
This is a recharacterization of a
current or prior year Traditional or Roth IRA contribution, or a
D eath Distribution. Death Distribution for Inherited IRA Accounts
recharacterization of a conversion to a Roth IRA. The deadline for
and Death Distribution for Roth IRA Accounts.
a prior year recharacterization is the due date of your federal tax
return, including extensions (generally October 15th).
Excess Contribution Removal. I am withdrawing the excess
contribution I made and any earnings attributable to such contribution.
D ivorce. By checking this box, I represent that the transfer is
Earnings will be removed with the excess contribution if corrected
payment to a former spouse pursuant to a decree of divorce or
before the Federal income tax-filing deadline, pursuant to Internal
Qualified Domestic Relations Order (QDRO). Please contact a
Revenue Code Section 408(d)(4) and IRS Publication 590. The IRS
shareholder services representative to determine what additional
may impose a 10% premature withdrawal penalty on the earnings if
documents are required.
you are under age 59 ½.
C overdell ESA Distribution. Distributions not used for qualified
education expenses may be subject to a penalty. No tax withholding
is permitted.
BU-DISTRB
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