CHARITABLE DISTRIBUTION REQUEST
The term IRA will be used to mean Traditional IRA and Roth IRA, unless otherwise specified.
PART 1. IRA OWNER
Social Security Number
Date of Birth Phone
Account Number Suffix
ACCOUNT TYPE (Select one)
Traditional IRA Roth IRA
PART 2. IRA TRUSTEE OR CUSTODIAN
To be completed by the IRA trustee or custodian
Address Line 1
Address Line 2
Phone Organization Number
PART 3. CHARITABLE DISTRIBUTION REQUIREMENTS
To be a qualified charitable distribution, the following statements must be true.
I will have attained age 70½ or older as of the date of this distribution.
The distribution meets the deductibility requirements under Internal Revenue Code Section (IRC Sec.) 170 and I certify that I will not receive any
additional benefit from the receiving organization in return for this charitable donation.
This distribution consists entirely of pretax assets from the IRA.
The amount of the charitable distribution from this IRA, when combined with all other qualified charitable distributions I will be taking in the
current year, will be less than or equal to the allowable limit (generally $100,000 potentially reduced by deductible contributions made for a year
in which I was age 70½ or older).
The receiving organization is a church, educational organization, medical organization, private foundation, or other charitable organization listed
under IRC Sec. 170(b)(1)(A).
PART 4. DISTRIBUTION INSTRUCTIONS
Distribution Amount Distribution Date
ASSET HANDLING (Assets identified below will be liquidated immediately unless otherwise specified in the Special Instructions section.)
Asset Description Amount to be Distributed Special Instructions
PAYMENT INSTRUCTIONS (The check will be made payable to the following charitable organization.)
Name of Charitable Organization
Donor of Record (IRA Owner’s name)
Send the check to the
IRA Owner Charitable Organization
PART 5. SIGNATURES
I certify that I am authorized to receive payments from this IRA and that all information provided by me is true and accurate. I understand and have
met the requirements for making a qualified charitable distribution from my IRA. No tax advice has been given to me by the trustee or custodian. All
decisions regarding this distribution are my own, and I expressly assume responsibility for any consequences that may arise from this distribution.
I agree that the trustee or custodian is not responsible for any consequences that may arise from processing this distribution.
Signature of IRA Owner Date (mm/dd/yyyy)
Notary Public/Signature Guarantee (If required by the trustee or custodian) Date (mm/dd/yyyy)
Authorized Signature of Trustee or Custodian Date (mm/dd/yyyy)
22 (Rev. 1/2020) ©2020 Ascensus, LLC
Kinecta Federal Credit Union
Attn: Member Service Support
Manhattan Beach, CA 90266