IRA Beneciary Claim
Page 3 of 5
589432 (Rev 09 - 02/19)
Withhold state income tax of % or $ from my IRA distribution.
If this is a total distribution, for the state of CT or for Washington, D.C., you can only elect
an amount greater than the state withholding minimum (CT is a 6.99% minimum, D.C. is a
Withhold federal income tax of % or $ from my IRA distribution.
ACH BANK INFORMATION
Account Number to Credit
Name on Account
Name of Bank
Type of Account
Section 5 Tax Withholding Certications and Elections
Required if the
Lump Sum option
was selected in
Withholding elections are made by choosing one option in the federal taxes and one option in
the state taxes section. If you are eligible to elect out of federal or state withholding
and decide to do so, you will be liable for taxes due on the taxable portion of your
distribution and potential penalties for underpayment of estimated taxes. You should
consult with your tax advisor before making your elections. After completing this form,
to make a change to a federal and/or state withholding election, a new form and signature are
required. The tax withholding election is for this distribution ONLY and does not revoke or change
any separate distribution instructions that may be on le.
You cannot elect out of the 10% mandatory withholding if you have not supplied Wells Fargo
Clearing Services, LLC 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.
Withholding is required in some states if federal withholding applies, unless you specically 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 CT: If you’ve opted out of state
tax withholding or elected an amount to withhold for partial or scheduled distributions, you are
electing withholding code “E,” as dened by Connecticut’s form CT-W4P.
IRS Transfer Certicates are generally required when an IRA holder, regardless of their citizenship,
passes away while residing outside of the United States and the decedent’s total U.S. assets (held
at Wells Fargo Clearing Services, LLC and elsewhere) exceeded $60,000 in value at the date of
death. In instances where IRS Transfer Certicates are required, the Transfer Certicates must be
obtained by the heirs or executor of the decedent and provided to WFCS before assets
are transferred out of the decedent’s IRA account. Applying for IRS Transfer Certicates
requires ling certain documents with the U.S. Internal Revenue Service and may have tax
implications for the decedent’s estate. Consequently, any heir, executor, or estate administrator/
Selection Required (choose one)
Selection Required (choose one) State taxes will be withheld based on the state listed on
your account registration.
Federal Taxes W-4P, OMB No.1547-0074
IRS Transfer Certicates
Do NOT withhold federal income tax from my IRA distribution.
Do NOT withhold state income tax from my IRA distribution. If this is a total distribution,
for the state of CT or for Washington, D.C., you cannot opt out of withholding.
Oce Use Only: Sub Firm BR Code FA Code: Account Number