13191 Starkey Rd., Suite 2
Largo, FL 33773
P: (800) 425-0653 | F: (866) 385-6045
Mr. Ms. Mrs. Dr.
Advanta IRA Account Number:
The asset in my account is:
CUSIP (Advanta Use):
Value of IRA ownership in this asset:
Date of Value:
Attached supporting documentation:
Name of Valuator:
Real Estate Professional
I certify that I am qualified to give an independent valuation/appraisal for this particular asset. I understand that this appraisal will be used for reporting
purposes to the Internal Revenue Service. I understand that any false or misleading valuation/appraisal of any assets may result in penalties and fines
for both the valuator/appraiser and the account owner.
Account Holder's Signature
I certify that I am the owner of the above referenced account and that in that capacity I have retained the services of the individual listed to
prepare, present, and attest to the value of the asset contained. I further certify that the information contained herein is true and accurate to the
best of my knowledge.
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This form must be signed by the account holder for Advanta IRA to accept it. Advanta IRA accepts emailed and faxed copies of this form.
The information on this form will be used for reporting purposes to the IRS. Advanta IRA encourages you to use a valuator and provide supporting
documents for each FMV.
A K-1 is not an acceptable document because it represents a historical value.
Note: A separate form is needed for each asset in your account. This form is not acceptable for ROTH conversions or account distributions.
Directed Retirement Plans