Distribution Request Form

DISTRIBUTION REQUEST FORM
Account Owner Information

The following is in regard to the iPlanGroup account owners information. Please be sure to fill out all fields in order to have the form submitted to iPlanGroup!
Account Owner Name*

First NameMiddle NameLast Name
iPlanGroup Account Number*
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Distribution Type

This will help us know which type of distribution you are looking to fulfil.
Will this distribution close your iPlanGroup account?*

YesNo
Is this a distribution from either an HSA or a CESA account?*

YesNo
Type of Distribution*

Early Distribution (no known exceptions)Early Distribution from a Roth IRAEarly Distribution (exception applies)Qualified Distribution from a Roth IRADeathEarly Distribution (from a SIMPLE IRA in the first 2 years, no known exception)Prohibited TransactionRoth IRA distribution (exception applies)Normal DistributionExcess Contributions plus earnings/excess deferrals taxable for the current tax year
Type of Distribution*

Qualified Medical Expense (HSA)Premature Distribution (CESA)Non-qualified: Under age 65 (HSA)Qualified Educational Expense (CESA)Non-qualified: Over age 65 (HSA)
Was the Contribution made in a prior year?*

YesNo
Is Contribution being removed prior to the tax return due date for which the Contribution was made?*

YesNo
METHOD OF PAYMENT

Please Note: Checks and/or assignment letters will be issued to the account owner and to the address on file unless indicated otherwise.
Which method should we use to process the funds?*

CheckWire (fees apply)ACH (fees apply)
How would you like us to send the check?*

Regular MailOvernight Mail (fees apply)Pickup at iPlanGroup
Wire/ACH Instructions*

Bank Name

State

CityState / Province
Bank Account Name
ABA Routing Number
Bank Account Number
Frequency of Distribution
Is this Distribution a One Time or Recurring?*

One Time DistributionRecurring Distributions
When would you like this Recurring Distribution to begin? *

MonthDayYear
Date
How often would you like us to process the Recurring Distribution?*

MonthlyQuarterly
Distribution Amount

This is where you will list the dollar amount/assets you would like us to distribute to you.
Is this a Cash or Asset Distribution?*

Only CashOnly AssetsBoth
Cash Distribution*

Partial Cash DistributionAll Available Cash Distribution
How much would you like us to send?*

Tax Withholding Election and Notice

Unless a previous election is in place or otherwise indicated below, 10% Federal Tax will be withheld from your IRA Distribution.
I want PERCENTAGE % or $DOLLARS of Federal Income Tax (not less than 10% or equivalent dollars) withheld from my Distribution.

Acknowledgement and Signature
By signing this Distribution Request Form, I certify that the information I have provided is true and correct, and I authorize the Trustee/Custodian to distribute my IRA as instructed above. I understand that I am responsible for ensuring I am eligible to authorize this distribution and I assume all responsibility for any consequences as a result of my actions. I will indemnify and hold the Trustee/Custodian harmless from any consequences related to executing my instructions, including payments made in error. I have been advised to seek competent legal and tax advice, and have not been provided any such advice from the Trustee/Custodian. I also understand that if this distribution involves a SIMPLE IRA, special rules apply, and I assume responsibility for my actions regarding those issues. I agree that any fees associated with this transaction will be debited from my account.
Account Owner Name*

First NameLast Name
Date*

MonthDayYear
Date
Client Signature*

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ABA Routing Number

Bank Account Number

CityState / Province

Postal / Zip Code
Should be Empty:

	Asset Description	Amount or %	In-Kind
Asset Details
Asset Details
Asset Details

DISTRIBUTION REQUEST FORM

Account Owner Information

Distribution Type

METHOD OF PAYMENT

Frequency of Distribution

Distribution Amount

Tax Withholding Election and Notice

Acknowledgement and Signature