Tax-Deferred Retirement Account (Tdra) Enrollment Form For Selfemployed Ministers

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TAX-DEFERRED RETIREMENT ACCOUNT
(TDRA) ENROLLMENT FORM FOR SELF-
EMPLOYED MINISTERS
- PLEASE TYPE OR PRINT CLEARLY -
I. APPLICANT INFORMATION
Full Legal Name
(first, middle, last/family name)
Title Preference:
Mr.
Mrs.
Miss
Ms.
Rev.
Dr.
Chap.
None
Social Security No./ITIN _______ - _____ - _________
Date of Birth ________/________/________
Gender:
M
F
Home Address
City ____________________________________ State
Country
Zip___________-
Home Phone (
)
Work Phone (
)
Cell Phone (
)
E-Mail Address
US Citizen (check one):
Yes
No, citizen of _____________________________ If you are not a US citizen, you must have an ITIN to enroll.
Check one:
Ordained
Commissioned IMPORTANT: Please provide a copy of your current credentials with this Form.
Date of ordination or first date of commission is ________/________/________.
II. CONTRIBUTION INFORMATION
The initial pre-tax contribution amount remitted to the TDRA on my behalf is $_________________________.
My current total compensation from self-employment (gross salary plus housing allowance) is $_________________________ .
III. DESIGNATION OF BENEFICIARIES
Designate the person, trust or entity you choose to receive any benefits payable from your 403(b) account under the TDRA in the event
of your death. If you designate a trust as a beneficiary, include the trust's name and address, the date the trust was created, and the
trustee's name. You are not limited to three primary and three contingent beneficiaries. To designate additional beneficiaries, please
attach and sign a separate piece of paper.
Unless otherwise indicated, death benefits will be paid in equal shares to your primary beneficiaries who are living at the time of your
death. If no primary beneficiary is living at your death, unless otherwise indicated, death benefits will be paid in equal shares to your
contingent beneficiaries who are living at the time of your death. If you name multiple primary or contingent beneficiaries, and one of
them predeceases you, the percentage of that beneficiary's designated share shall be divided equally among the surviving primary or
contingent beneficiaries, as applicable.
IMPORTANT: If you do not elect a beneficiary, or if your beneficiaries named on this Enrollment Form fail to survive you,
your benefits will be paid to your spouse, or if none, your benefits will be paid to your estate. Failure to include a social
security number for each designated beneficiary, if applicable, may delay distributions at your death.
Primary Beneficiaries
Percentage
The total percentage to all primary beneficiaries must equal 100%.
of Benefit
Individual or Trust Name __________________________________________________________________________________
__________%
(first, middle, last/family name)
Mailing Address _________________________________________________________________________________________
(street, city, state, zip)
Primary Phone (
)
Relationship to Applicant/Trustee Name ________________________________
Social Security No./ITIN _______ - _____ - _________ Birth or Trust Date ________/________/________
Individual or Trust Name __________________________________________________________________________________
__________%
(first, middle, last/family name)
Mailing Address _________________________________________________________________________________________
(street, city, state, zip)
Primary Phone (
)
Relationship to Applicant/Trustee Name ________________________________
Social Security No./ITIN _______ - _____ - _________ Birth or Trust Date ________/________/________
Page 1 of 3
TDRA Enrollment Form for Self-Employed Ministers 03-15
4927828v2

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