Pensco Ira Application Form
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1
2Please return original to:
Regular Mail:
Overnight Delivery Only:
P.O. Box 26903
450 Sansome Street, Fl. 14
San Francisco, CA
San Francisco, CA
94126-6903
94111-3306
Call 866-818-4IRA (4472) for help completing this form.
1. Depositor Information
First Name
Middle Last
Suffix
Online Login
Date of Birth
Social Security #
Password
Month
Day
Year
(4-10 Characters, numbers and/or letters)
Primary
Secondary
Fax #
Phone #
Phone #
Physical Address (required)
Address
City
State
Zip Code
Mailing Address
Check if same as physical address
Address
City
State
Zip Code
Email Address (Important)
(For notifying you of transactions or information
pertaining to your IRA)
Online Quarterly Statement - By checking here I elect to receive my quarterly statement electronically (and not as a paper version) when this option becomes available.
2. Type of Account
IRA
SEP IRA (P
lease submit the enclosed IRS Form 5305-SEP along with this application.)
Roth IRA
3. Beneficiary Designation
Please Note:
For primary beneficiaries that are Trusts, Wills, or Estates, please include a copy of the related legal documents (i.e. beneficiary and signature pages). Primary
shares and secondary shares each must each add up to 100%. If you have more than two beneficiaries, please provide their information on our Additional Beneficiaries Form.
You can download this form at
Primary
(required)
Primary Share
%
(All Primary Beneficiary shares must add up to 100%, i.e. if you only have one Primary Beneficiary, put 100%: If you have two equal primary beneficiaries, put 50% and 50%)
Percentage:
Name of Individual, Trust, Will, Institution, etc.
Date of Birth
(or Establishment)
Relationship to the Depositor
Social Security # / Tax ID
Month
Day
Year
Address
City
State
Zip Code
Additional Primary
Secondary
or
(optional; if supplying, please check whether Primary or Secondary)
Primary Share
Secondary Share
%
OR
%
Percentage:
Percentage:
(Secondary Beneficiary shares must add up to 100%, i.e. if you only have one Secondary Beneficiary, put 100%).
Name of Individual, Trust, Will, Institution, etc.
Date of Birth
(or Establishment)
Relationship to the Depositor
Month
Day
Year
Social Security # / Tax ID
Address
City
State
Zip Code
4. Spousal Consent
_________________________________________________________
________________
Spousal signature required if the Primary Beneficiary is other than the spouse and the Depositor is
subject to laws of a community property state. I consent to the above Beneficiary Designation:
Spousal Signature
Date
For Office Use Only
O
B S A D
R C
I
X
Book
Set Up
Officer Review/Acceptance
OVER
TF-APP-01-1205
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