Name
IRA Contribution Transmittal Form
This form can be used to remit a contribution by check -OR-
initiate, modify, or cancel an ACH authorization.
STEP 1
ACCOUNT HOLDER AND BANK INFORMATION
New Updated Cancel
IRA ACCOUNT BANK ACCOUNT CONTRIBUTION YEAR* ASPIRE IRA ACCT#
Traditional Roth | Checking Savings
(Check Only) (If Available)
First Name Last Name
Social Security Number
FOR AUTOMATED CLEARING HOUSE (ACH) AUTHORIZATIONS ONLY
Indicated below is the depository financial institution, hereinafter called DEPOSITORY, for the account from which the ACH will be debited.
Account Holder acknowledges that the origination of ACH transactions to the IRA account must comply with the provisions of U.S. law.
Bank Name Branch
Address
City State Zip
STEP 2
SUBMISSION INSTRUCTIONS
CHECK – Attach executed check and mail original
Make checks payable to: Benefit Trust Company FBO “Account Holder Name.”
In the memo: Be sure to include the Aspire IRA Account number.
Mail this form and check to the following address:
Aspire Financial Services, LLC, 4010 Boy Scout Blvd., Suite 500, Tampa, FL 33607
ACH – Attach Deposit Slip for Account from which the ACH will be debited.
Account Holder acknowledges and agrees that:
• For all ACH contributions, the year in which the ACH amount was processed will be the contribution year; it may not be retroactiv
e.
• For the 1st ACH debit processing time can take up to one month after receipt of the request. Once started, the ACH debit will
occur on or about the 15th of each month.
Name
Pay to the order of
$
11234567891 12233582492 0001
Pay to the
order of
DO NOT INCLUDE CHECK
NUMBER
0001
Routing Number Account Number
$
ACH: Attach void check for Account from which the
ACH will be debited Here. (MAY BE FAXED)
11234567891 12233582492 0001
Routing Number Account Number
*If the contribution year is not notated above, Aspire will use the year in which the contribution was received.
STEP 3
AUTHORIZATION & SIGNATURE (ACH ONLY)
Account Holder acknowledges and agrees that, if the Depository for the account from which the ACH will be debited requires more than 1
signature for this authorization and any subsequent revocation, the Account Holder will provide those names and signatures to Aspire in
addition to this IRA Contribution Transmittal Form. For ACH this authorization is to remain in full force and effect until Aspire has received
written notification from Account Holder of its termination in time and such manner as to afford Aspire and DEPOSITORY a reasonable
opportunity to act on it.
Account Holder Name
Account Holder Signature
Date (month | day | year)
Fax this form to 813.425.9781 or mail to: Aspire, 4010 Boy Scout Blvd., Suite 500, Tampa, FL 33607. Maintain a copy for your records.
Questions? Call Client Services at 866.634.5873, M - F, 8am - 8pm ET.
Contribution Transmittal Form - Benefit Trust Company F4710-0913-01
