Crypto Application General

1
What type of account would you like to establish?* This field is required.
Traditional IRA
Roth IRA
SEP IRA
SIMPLE IRA
Self Directed HSA
Solo 401(k)
Youth Account (17 Yrs or Younger)
2
Name* This field is required.
First Name
Last Name
3
Street Address* This field is required.
4
City* This field is required.
5
State* This field is required.
6
Zip Code* This field is required.
7
DATE OF BIRTH* This field is required.
Date
Month
Day
Year
8
Social Security Number* This field is required.
9
PHONE NUMBER* This field is required.
10
EMAIL ADDRESS* This field is required.
example@example.com
11
How will you Fund Your Account?* This field is required.(Please note, each account requires a $500 minimum cash balance)
IRA to IRA Transfer
Old Employer Plan (401k, 403b, 457, TSP)
Contribution
Pension/Annuity
12
Here is a guide to help you with your rollover.This guide will also be attached in your email as a link.
13
Firm Name* This field is required.
American Funds
Edward Jones
E-Trade
Fidelity
LPL Financial
Pershing
Charles Schwab
TD Ameritrade
Vanguard
Other
14
Enter Other Firm Name
15
Transfer Amount (approximately)
16
Please Upload Supporting Documents(Optional)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
17
Old Employers Firm Name* This field is required.
18
Rollover Amount (approximately)* This field is required.
19
Tax Year for Contribution* This field is required.
20
Would you like to add a beneficiary?
Yes
No
21
Beneficiary's Full Name* This field is required.
22
Beneficiary's DOB
Date
Month
Day
Year
23
Beneficiary's Social Security Number
24
Share Percentage * This field is required.
25
Relationship to Account Owner* This field is required.
26
How did you hear about IRA Club?
27
Initials* This field is required.By signing this application, I acknowledge, on behalf of myself and all users authorized by me, that: I agree to accept electronic statements and notices via email and online to my IRA Club portal. IRA Club will provide a unique Contact ID to set up a User ID, Password, and Security Questions. Online access registration will be sent to the email address above within five business days after the account is active. The password chosen will be kept confidential. If a User ID or Password is lost or stolen, I will attempt to reset it or call IRA Club to obtain assistance. I agree to hold IRA Club harmless from all losses, liability, demands, judgments, claims, and expenses from my use of my email address listed above, the IRA Club website, and the IRA Club Portal IRA Club provides. I provide the indemnification without regard as to whether your claim is against my authorized representative or me.
28
Signature Date* This field is required.
Date
Month
Day
Year
29
Terms and Conditions* This field is required.
30
Crypto Terms and Conditions.* This field is required.
31
SignatureThis application consists of three parts provided for review. By signing this application, I hereby establish an IRA under the provided Custodial Agreement (Form 5305) and Account Disclosure Statement. I designate IRA Club as my IRA Administrator. I agree to the terms outlined in the application and have read and examined the IRA Custodial Account Agreement (5305), Account Disclosure, and IRA Club Fee Schedule. I have retained a copy of my account documents, including a copy of this completed application. Please note, each account requires a $500 minimum cash balance.
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