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Distribution Request from IRA
Sub Firm #
BR Code
FA Code
Account Number
(Office Use Only)
Complete this form if you wish to take a withdrawal from your First Clearing, LLC (“FCC”) IRA. It is your responsibility to provide us with accurate information, which will be used
to report the distribution to the IRS. Before completing this form, please review the important information on page 3 and consult with your tax advisor to be clear as to the tax
implications, if any.
Please note: Do not complete this form if you want to withdraw Substantially Equal Periodic Payments based on IRC 72(t), convert your Traditional IRA to a Roth IRA, remove
an excess contribution, or recharacterize a contribution. Different forms are needed to complete these transactions:
•
Substantially Equal Periodic Payments based on IRC 72(t) - complete the SEPP/72(t) Distribution Request form (592240).
•
Convert a Traditional IRA to a Roth IRA - complete the Roth Conversion form (585756).
•
Remove an excess contribution or recharacterize a contribution - complete the IRA Recharacterization or Removal of Excess Contribution form (589978).
IRA Holder Name
SSN (last 5 digits)
IRA Type
(choose one)
Traditional
SEP
Recipient Name (Complete Recipient Section if different than IRA Holder)
Recipient's Social Security/Tax ID Number
Recipient's Date of Birth
SIMPLE
Recipient Address
City
State
Zip Code
Roth
Inherited
REASON FOR DISTRIBUTION
A new form and signature are required to change from one category to another.
Normal
(after age 59½)
Early SIMPLE
(date of first deposit):
Death
Disability
Premature
(before age 59½)
IRA to QRP
(Attach Letter of Acceptance from QRP)
Divorce
DISTRIBUTION INSTRUCTIONS
First Clearing, LLC is authorized to distribute as indicated below.
Type
Choose only one distribution type per form; a separate form is needed for each distribution type.
Partial (one time)
Periodic (recurring)
Termination of Entire Account (fees apply)
On-Demand - This selection provides the option to verbally authorize partial distributions from this IRA. Your selections below will be used as
standing instructions. Multiple distribution methods may be selected. Upon completion of this form, a distribution may be requested immediately.
Please see On-Demand Distribution section on page 3 for additional information.
Method
Check:
Payable to:
Mail to Address of Record
Mail to above Recipient Address
Hold for Pick-Up at Branch
Mail to Address:
Journal to Account Number
Account Name
FedWire Funds: Fees Apply - Fill out wire instructions on page 4.
Deposit electronically via ACH
(provide required information below.)
ACH BANK INFORMATION
Name on Account
Name of Bank
Type of Account
Checking or
Savings
Bank City
Account Number to Credit
Bank State
ABA/Routing #
Periodic
Establishing New - effective
(1st - 28th)
Frequency:
Weekly
Quarterly (every 3 months)
/
/
Distribution
Monthly
Semi-Annually (every 6 months)
Change Existing - effective
/
/
Semi-Monthly (2 times/month)
Annually (once a year)
Cancel Existing Instructions
/
/
Amount
Cash: Amount $
Securities: Specify assets
Symbol or CUSIP:
Number of Shares:
Annual Required Minimum Distribution (RMD)
Net of taxes
Gross of taxes (applicable fees and withholding
will be deducted from this amount.)
Separately signed page attached for additional assets.
Periodic Distributions only:
Dividends (DIV)
Interest (INT)
Other:
SR #
585254 (Rev 15 - 03/15) Page 1 of 4