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
Please verify the last 4 of your SSN*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
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.
YesNo
YesNo
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
IRS 1099-R Guide to Distribution Codes
Qualified Medical Expense (HSA)Premature Distribution (CESA)Non-qualified: Under age 65 (HSA)Qualified Educational Expense (CESA)Non-qualified: Over age 65 (HSA)
YesNo
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.
CheckWire (fees apply)ACH (Gross Distribution Amount Can NOT Exceed $15,000; fees apply)
Regular MailOvernight Mail (fees apply)Pickup at iPlanGroup
Wire/ACH Instructions*

Bank Name

State

CityState / Province

Zip Code
Bank Account Name*
Person on the Account
Bank Street Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
ABA Routing Number
Bank Account Number
Frequency of Distribution
One Time DistributionRecurring Distributions
When would you like this Recurring Distribution to begin? *

MonthDayYear
Date
MonthlyQuarterly
Distribution Amount

This is where you will list the dollar amount/assets you would like us to distribute to you.
Only CashOnly AssetsBoth
Partial Cash DistributionAll Available Cash Distribution
Gross Distribution Amount*

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.

IRS IRA FAQs - Distributions (withdrawals)
Account Owner Name*

First NameLast Name
Date*

MonthDayYear
Date
Client Signature*

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Additional Notes for Processor (if applicable)
ABA Routing Number

Bank Account Number

CityState / Province

Postal / Zip Code
Should be Empty:

Rows	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