Traditional, Sep, Or Simple Ira Distribution Form Page 2
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1
2Quest IRA, Inc.
Traditional, SEP, or SIMPLE IRA
17171 Park Row, Suite 100
Houston, TX 77084
Distribution Form
P: 800.320.5950
F: 281.646.9701
Until I give written instructions to the contrary, I direct Quest IRA, Inc. to distribute the amount requested as follows:
Date to commence: ______________________________
Frequency:
[ ] One Time
[ ] Monthly
[ ] Quarterly
[ ] Semi-Annually
[ ] Annually
[ ] Check
Send check to: [ ] Home Address
[ ] Wire
[ ] Different Address: _______________________________________
[ ] ACH
For Wires or ACH:
Name of Bank: __________________________________________ Account Name: ____________________________________
Bank ABA/Routing Number: __________________________________ Account Number: ________________________________
NOTICE OF WITHHOLDING ON DISTRIBUTIONS FROM IRAS
The distributions you receive from your individual retirement account established at this institution are subject to federal income tax
withholding unless you elect not to have withholding apply.
You may elect not to have withholding apply to your distribution payments by completing the “Withholding Election” section above.
If you do not complete the “Withholding Election” section by the date your distribution is scheduled to begin, federal income tax will
be withheld from the amount withdrawn at a rate of 10%.
If you elect not to have withholding apply to your distribution payments, or if you do not have enough federal income tax withheld
from your distribution, you may be responsible for payment of estimated tax. You may incur penalties under the estimated tax rules
if your withholding and estimated tax payments are not sufficient.
WITHHOLDING ELECTION
Option 1.
[ ]
I elect to HAVE federal income taxes withheld from my IRA distribution at the rate of __________ % (not less than
10%) plus an additional amount of $_____________ from the amount withdrawn.
Option 2.
[ ]
I elect to NOT HAVE federal income taxes withheld from my IRA distribution. (Must have a US residence address
on file)
I understand that I am still liable for the payment of federal income tax on the taxable amount. I also understand that I may be
subject to tax penalties under the estimated tax payment rules, if my payments of estimated tax and withholding, if any, are not
adequate.
PAYMENT OF FEES
Payment of fees associated with processing of the distribution shall be paid:
[ ] From Account
[ ] Credit Card Authorization Form attached
Note: There are no applicable fees for required minimum distributions by check.
AUTHORIZATION
I certify that I am the proper party to receive payment(s) from this IRA, and that all information provided by me is true and accurate.
I acknowledge that I have read the Notice of Withholding below and have completed the Withholding Election above. I further
certify that no tax advice has been given to me by Quest IRA, Inc. or the Custodian, that distributions (except certain transfers) are
reported to the IRS, and that all decisions regarding this withdrawal are my own. I expressly assume the responsibility for any
adverse consequences which may arise from this withdrawal and I agree that Quest IRA, Inc. and the Custodian shall in no way be
responsible for those consequences.
Account Holder’s Signature: ______________________________________________ Date:_______ _____________________
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