distributionrequestfromira - tradepmr · !!!!!1"!account!information!...
TRANSCRIPT
Account Information 1
Distribution Request from IRA Complete this form if you wish to take a withdrawal from your First Clearing* IRA. It is your responsibility to provide us with accurate information which will be used to report the distribution to the IRS. Please consult with your tax advisor before completing this form. READ IMPORTANT INFORMATION ON PAGE 2 PRIOR TO COMPLETING THIS FORM.
Account Number: IRA Account Holder Name: Sub Firm:
211 IRA Account Type: ☐Traditional ☐Rollover ☐Roth ☐SEP ☐Simple ☐Beneficiary
Recipient Information (Complete Recipient Section only if different than IRA Account Holder) Recipient Name: Recipient’s Social Security Number/Tax ID: Recipient’s Date of Birth:
Recipient Address: City: State: Zip Code:
☐Normal (after age 59½) ☐72(t)(Premature, exception to penalty) ☐Death ☐Disability
☐Premature (before age 59½) ☐IRA to QRP (Attach Letter of Acceptance from QRP) ☐Divorce ☐Early SIMPLE (date of first deposit):
Withholding elections are made by choosing one option in the Federal Taxes & one option in the State Taxes section. If you are eligible to elect out of Federal or State withholding & decide to do so, you will be liable for taxes due on the taxable portion of your distribution & potential penalties for underpayment of estimated taxes. You should consult with your tax advisor before making your elections. To withhold taxes from on-‐demand distributions, elect a withholding percentage; a dollar amount is not permitted. After completing this form, to make a change to a Federal and/or State withholding election, a new form and signature are required. ��������������������� Federal Taxes
W-‐4/OMB No. 1545-‐0074
You cannot elect out of the 10% mandatory withholding if you have not supplied FCC with your correct SSN or TIN and a “residence address” within the United States. If no election is made we are required to withhold Federal income taxes at a rate of 10% of the gross distribution amount. If you elect to withhold a percentage or a dollar amount, the value must be equal to or greater than 10% of the gross distribution amount. Selection Required (choose one) ☐Do NOT withhold Federal income tax from my IRA distribution. ☐Withhold Federal income tax of % or $ from my IRA distribution.
State Taxes
Withholding is required in some states if Federal withholding applies, unless you specifically elect out. Residents of CA or VT: The withholding rate applies to the Federal withholding amount and not the gross distribution amount. Residents of MI: If you elect out, you are certifying your distribution is not taxable because you were born before 1946 or you believe that you will not have a balance due on your MI-‐1040. Residents of Washington DC: Taxes will be withheld at the rate of 8.95% on total distributions with no option to elect out. Selection Required (choose one) State taxes will be withheld based on the state listed on your account registration. ☐Do NOT withhold State income tax from my IRA distribution. ☐Withhold State income tax of % or $ from my IRA distribution.
Type (choose one)
☐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 two for additional information.
Method ☐Check (mailed to the address of record) ☐Regular US Mail ☐Overnight Mail (fees apply)
☐FedWire Funds Domestically (fees apply – Attach Wire Authorization Form)
☐Journal Funds to: ☐ Non-‐IRA or ☐ IRA Brokerage
Account Number:
Account Name:
☐Deposit electronically via ACH ☐Checking or ☐Savings A VOIDED CHECK MUST BE ATTACHED Name on Bank Account:
Name of Bank:
City: State:
ABA/Routing #:
Account #:
Periodic Distribution*
☐Establishing New – effective: (1st-‐28th) Frequency: ☐Weekly ☐Quarterly (every 3 months) ☐Change Existing – effective: ☐Monthly ☐Semi-‐Annually (every 6 months) ☐Cancel Existing Instructions ☐Semi-‐Monthly (2 times/month) ☐Annually (once a year) *If no beginning date is specified, distributions will occur when the request is received and accepted by TradePMR.
Amount ☐Cash: Amount $ ☐Securities: Specify assets
☐Annual Required Minimum Distribution (RMD) Symbol or CUSIP: Number of Shares: ☐Net of taxes ☐Separately signed page attached for additional assets. ☐Gross of taxes (applicable fees and withholding will be deducted from this amount.)
Periodic Distributions Only: ☐Dividends (DIV) ☐Interest (INT) ☐Other:
Reason for Distribution – A NEW FORM AND SIGNATURE ARE REQUIRED TO CHANGE FROM ONE CATEGORY TO ANOTHER2
Tax Withholding3
Distribution Instructions – FIRST CLEARING IS AUTHORIZED TO DISTRIBUTE AS INDICATED BELOW.
Certification5 I certify that I am the proper party to receive payment(s) from this IRA and that all information provided is true and accurate. I further certify that no tax advice has been given to me by First Clearing, my Financial Advisor or the brokeri dealer servicing my account. I expressly assume the responsibility for any tax implications and any adverse consequences which may arise from this withdrawal. I agree that First Clearing, and any of its affiliates may reasonably rely on my certification without further
investigation or inquiry and shall not be liable for any misrepresentation of fact.Signature of IRA Holder, POA, or Beneficiary Print Name Date
DIST.2014.8.13.04 Securely email, fax or mail completed forms to: [email protected] / 352-224-1343 / PO Box 358230, Gainesville, FL 32635
*Account(s) carried by First Clearing. First Clearing is a trade name used by Wells Fargo Clearing Services, LLC, a registered broker-dealer and non-bank affiliate of Wells Fargo & Company.
4