Fill - Free fillable IRA Simplifier ROTH INDIVIDUAL RETIREMENT ACCOUNT APPLICATION (Georgia's Own Credit Union) PDF form

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PART 1. ROTH IRA OWNER

Name (First/MI/Last) _________________________________________

Address Line 1 ______________________________________________

Address Line 2 ______________________________________________

City/State/ZIP _______________________________________________

Social Security Number _______________________________________

Date of Birth ____________________ Phone _____________________

Email Address _______________________________________________

Account Number ____________________________________________

PART 2. ROTH IRA TRUSTEE

To be completed by the Roth IRA trustee

Name _____________________________________________________

Address Line 1 ______________________________________________

Address Line 2 ______________________________________________

City/State/ZIP _______________________________________________

Phone _______________________ Organization Number ___________

This is an amendment to an existing Roth IRA.

This Roth IRA contains managed investments as described in the

Trustee Management of Investment section of the agreement.

PART 3. CONTRIBUTION INFORMATION

Contribution Amount ____________________________ Contribution Date ________________

CONTRIBUTION TYPE (Select one)

1. Regular (Includes catch-up contributions)

Contribution for Tax Year _________

2. Rollover (Distribution from a Roth IRA or eligible employer-sponsored retirement plan that is being deposited into this Roth IRA)

By selecting this transaction, I irrevocably designate this contribution as a rollover.

3. Transfer (Direct movement of assets from a Roth IRA into this Roth IRA)

4. Recharacterization (A nontaxable movement of a Traditional IRA contribution into this Roth IRA)

By selecting this transaction, I irrevocably designate this contribution as a recharacterization.

5. Conversion (A taxable movement from a Traditional IRA or SIMPLE IRA into this Roth IRA)

By selecting this transaction, I irrevocably designate this contribution as a conversion.

PART 4. INVESTMENT AND DEPOSIT INFORMATION

INVESTMENT INFORMATION (Complete this section as applicable.)

Investment Description Quantity or Amount Investment Number Term or Maturity Date Interest Rate

__________________________________________________ ________________________ ____________________ ____________________ ___________

DEPOSIT METHOD

Cash or Check (If the contribution type is transfer, the check must be from a financial organization made payable to the trustee for this Roth IRA.)

Internal Account

Account Number _____________________________________________ Type (e.g., checking, savings, IRA) ________________________________

External Account (e.g., EFT, ACH, wire) (Additional documentation may be required and fees may apply.)

Name of Organization Sending the Assets ___________________________________________ Routing Number (Optional) ___________________

Account Number _____________________________________________ Type (e.g., checking, savings, IRA) ________________________________

Deposit Taken by_____________________________________

ROTH INDIVIDUAL RETIREMENT ACCOUNT APPLICATION

Simplifier

ROTH

IRA

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Check here if additional beneficiaries are listed on an attached addendum. Total number of addendums attached to this Roth IRA ______________

PART 6. SPOUSAL CONSENT

Spousal consent should be considered if either the trust or the residence of

the Roth IRA owner is located in a community or marital property state.

CURRENT MARITAL STATUS

I Am Not Married – I understand that if I become married in the

future, I should review the requirements for spousal consent.

I Am Married – I understand that if I choose to designate a primary

beneficiary other than or in addition to my spouse, my spouse should

sign below.

CONSENT OF SPOUSE

I am the spouse of the above-named Roth IRA owner. I acknowledge that I

have received a fair and reasonable disclosure of my spouse’s property and

financial obligations. Because of the important tax consequences of giving

up my interest in this Roth IRA, I have been advised to see a tax professional.

I hereby relinquish any interest that I may have in this Roth IRA and

consent to the beneficiary designation indicated above. I assume full

responsibility for any adverse consequences that may result.

X____________________________________________ _____________________

Signature of Spouse Date (mm/dd/yyyy)

X____________________________________________ _____________________

Signature of Witness Date (mm/dd/yyyy)

PART 7. SIGNATURES

Important: Please read before signing.

I understand the eligibility requirements for the type of Roth IRA contribution I

am making, and I state that I do qualify to make the contribution. I have received

a copy of the Roth IRA Application, 5305-R Trust Account Agreement, the

Financial Disclosure, and the Disclosure Statement. I understand that the terms

and conditions that apply to this Roth IRA are contained in this Application and

the Trust Account Agreement. I agree to be bound by those terms and

conditions. Within seven days from the date I open this Roth IRA I may revoke it

without penalty by mailing or delivering a written notice to the trustee.

I assume complete responsibility for

• determining that I am eligible for a Roth IRA each year I make a

contribution,

• ensuring that all contributions I make are within the limits set forth

by the tax laws, and

• the tax consequences of any contributions (including rollover

contributions and conversions) and distributions.

X____________________________________________ _____________________

Signature of Roth IRA Owner Date (mm/dd/yyyy)

X____________________________________________ _____________________

Signature of Witness Date (mm/dd/yyyy)

X____________________________________________ _____________________

Signature of Trustee Date (mm/dd/yyyy)

PART 5. BENEFICIARY DESIGNATION

I designate that upon my death, the assets in this account be paid to the beneficiaries named below. The interest of any beneficiary that predeceases

me terminates completely, and the percentage share of any remaining beneficiaries will be increased on a pro rata basis. If no beneficiaries are

named, my estate will be my beneficiary.

I elect not to designate beneficiaries at this time and understand that I may designate beneficiaries at a later date.

Name ______________________________________________________

Address ____________________________________________________

City/State/ZIP _______________________________________________

Date of Birth _________________ Relationship ___________________

Tax ID (SSN/TIN) ____________________ Percent Designated ________

Name ______________________________________________________

Address ____________________________________________________

City/State/ZIP _______________________________________________

Date of Birth _________________ Relationship ___________________

Tax ID (SSN/TIN) ____________________ Percent Designated ________

Name ______________________________________________________

Address ____________________________________________________

City/State/ZIP _______________________________________________

Date of Birth _________________ Relationship ___________________

Tax ID (SSN/TIN) ____________________ Percent Designated ________

Name ______________________________________________________

Address ____________________________________________________

City/State/ZIP _______________________________________________

Date of Birth _________________ Relationship ___________________

Tax ID (SSN/TIN) ____________________ Percent Designated ________

CONTINGENT BENEFICIARIES (The total percentage designated must equal 100%. If more than one beneficiary is designated and no percentages

are indicated, the beneficiaries will be deemed to own equal share percentages in the Roth IRA. The balance in the account will be payable to these

beneficiaries if all primary beneficiaries have predeceased the Roth IRA owner.)

Name ______________________________________________________

Address ____________________________________________________

City/State/ZIP _______________________________________________

Date of Birth _________________ Relationship ___________________

Tax ID (SSN/TIN) ____________________ Percent Designated ________

Name ______________________________________________________

Address ____________________________________________________

City/State/ZIP _______________________________________________

Date of Birth _________________ Relationship ___________________

Tax ID (SSN/TIN) ____________________ Percent Designated ________

Name ______________________________________________________

Address ____________________________________________________

City/State/ZIP _______________________________________________

Date of Birth _________________ Relationship ___________________

Tax ID (SSN/TIN) ____________________ Percent Designated ________

Name ______________________________________________________

Address ____________________________________________________

City/State/ZIP _______________________________________________

Date of Birth _________________ Relationship ___________________

Tax ID (SSN/TIN) ____________________ Percent Designated ________

PRIMARY BENEFICIARIES (The total percentage designated must equal 100%. If more than one beneficiary is designated and no percentages are

indicated, the beneficiaries will be deemed to own equal share percentages in the Roth IRA.)

Name of Roth IRA Owner ______________________________________________________________, Account Number ________________________

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The grantor named on the application is establishing a Roth individual

retirement account under section 408A to provide for his or her retirement

and for the support of his or her beneficiaries after death.

The trustee named on the application has given the grantor the disclosure

statement required by Regulations section 1.408-6.

The grantor has assigned the trust account the sum indicated on the

application.

The grantor and the trustee make the following agreement:

ARTICLE I

Except in the case of a rollover contribution described in section 408A(e),

a recharacterized contribution described in section 408A(d)(6), or an IRA

conversion contribution, the trustee will accept only cash contributions up

to $3,000 per year for tax years 2002 through 2004. That contribution limit

is increased to $4,000 for tax years 2005 through 2007 and $5,000 for

2008 and thereafter. For individuals who have reached the age of 50

before the close of the tax year, the contribution limit is increased to

$3,500 per year for tax years 2002 through 2004, $4,500 for 2005, $5,000

for 2006 and 2007, and $6,000 for 2008 and thereafter. For tax years after

2008, the above limits will be increased to reflect a cost-of-living

adjustment, if any.

ARTICLE II

1. The annual contribution limit described in Article I is gradually reduced

to $0 for higher income levels. For a single grantor, the annual

contribution is phased out between adjusted gross income (AGI) of

$95,000 and $110,000; for a married grantor filing jointly, between AGI

of $150,000 and $160,000; and for a married grantor filing separately,

between AGI of $0 and $10,000. In the case of a conversion, the

trustee will not accept IRA conversion contributions in a tax year if the

grantor’s AGI for the tax year the funds were distributed from the

other IRA exceeds $100,000 or if the grantor is married and files a

separate return. Adjusted gross income is defined in section 408A(c)(3)

and does not include IRA conversion contributions.

2. In the case of a joint return, the AGI limits in the preceding paragraph

apply to the combined AGI of the grantor and his or her spouse.

ARTICLE III

The grantor’s interest in the balance in the trust account is nonforfeitable.

ARTICLE IV

1. No part of the trust account funds may be invested in life insurance

contracts, nor may the assets of the trust account be commingled with

other property except in a common trust fund or common investment

fund (within the meaning of section 408(a)(5)).

2. No part of the trust account funds may be invested in collectibles

(within the meaning of section 408(m)) except as otherwise permitted

by section 408(m)(3), which provides an exception for certain gold,

silver, and platinum coins, coins issued under the laws of any state, and

certain bullion.

ARTICLE V

1. If the grantor dies before his or her entire interest is distributed to him

or her and the grantor’s surviving spouse is not the designated

beneficiary, the remaining interest will be distributed in accordance

with (a) below or, if elected or there is no designated beneficiary, in

accordance with (b) below:

(a) The remaining interest will be distributed, starting by the end of

the calendar year following the year of the grantor’s death, over

the designated beneficiary’s remaining life expectancy as

determined in the year following the death of the grantor.

(b) The remaining interest will be distributed by the end of the

calendar year containing the fifth anniversary of the grantor’s

death.

2. The minimum amount that must be distributed each year under

paragraph 1(a) above is the account value at the close of business on

December 31 of the preceding year divided by the life expectancy (in

the single life table in Regulations section 1.401(a)(9)-9) of the

designated beneficiary using the attained age of the beneficiary in the

year following the year of the grantor’s death and subtracting 1 from

the divisor for each subsequent year.

3. If the grantor’s surviving spouse is the designated beneficiary, such

spouse will then be treated as the grantor.

ARTICLE VI

1. The grantor agrees to provide the trustee with all information

necessary to prepare any reports required by sections 408(i) and

408A(d)(3)(E), Regulations sections 1.408-5 and 1.408-6, or other

guidance published by the Internal Revenue Service (IRS).

2. The trustee agrees to submit to the IRS and grantor the reports

prescribed by the IRS.

ARTICLE VII

Notwithstanding any other articles which may be added or incorporated,

the provisions of Articles I through IV and this sentence will be controlling.

Any additional articles inconsistent with section 408A, the related

regulations, and other published guidance will be invalid.

ARTICLE VIII

This agreement will be amended as necessary to comply with the

provisions of the Code, the related Regulations, and other published

guidance. Other amendments may be made with the consent of the

persons whose signatures appear on the application.

ARTICLE IX

9.01 Definitions – In this part of this agreement (Article IX), the words

“you” and “your” mean the grantor. The words “we,” “us,” and

“our” mean the trustee. The word “Code” means the Internal

Revenue Code, and “regulations” means the Treasury regulations.

9.02 Notices and Change of Address – Any required notice regarding

this Roth IRA will be considered effective when we send it to the

intended recipient at the last address that we have in our records.

Any notice to be given to us will be considered effective when we

actually receive it. You, or the intended recipient, must notify us of

any change of address.

9.03 Representations and Responsibilities – You represent and warrant

to us that any information you have given or will give us with

respect to this agreement is complete and accurate. Further, you

agree that any directions you give us or action you take will be

proper under this agreement, and that we are entitled to rely upon

any such information or directions. If we fail to receive directions

from you regarding any transaction, if we receive ambiguous

directions regarding any transaction, or if we, in good faith, believe

that any transaction requested is in dispute, we reserve the right to

take no action until further clarification acceptable to us is received

from you or the appropriate government or judicial authority. We

ROTH INDIVIDUAL RETIREMENT TRUST ACCOUNT AGREEMENT

Form 5305-R under section 408A of the Internal Revenue Code. FORM (Rev. March 2002)

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will not be responsible for losses of any kind that may result from

your directions to us or your actions or failures to act, and you

agree to reimburse us for any loss we may incur as a result of such

directions, actions, or failures to act. We will not be responsible for

any penalties, taxes, judgments, or expenses you incur in connection

with your Roth IRA. We have no duty to determine whether your

contributions or distributions comply with the Code, regulations,

rulings, or this agreement.

We may permit you to appoint, through written notice acceptable

to us, an authorized agent to act on your behalf with respect to this

agreement (e.g., attorney-in-fact, executor, administrator,

investment manager), but we have no duty to determine the

validity of such appointment or any instrument appointing such

authorized agent. We will not be responsible for losses of any kind

that may result from directions, actions, or failures to act by your

authorized agent, and you agree to reimburse us for any loss we

may incur as a result of such directions, actions, or failures to act by

your authorized agent.

You will have 60 days after you receive any documents, statements,

or other information from us to notify us in writing of any errors or

inaccuracies reflected in these documents, statements, or other

information. If you do not notify us within 60 days, the documents,

statements, or other information will be deemed correct and

accurate, and we will have no further liability or obligation for such

documents, statements, other information, or the transactions

described therein.

By performing services under this agreement we are acting as your

agent. Unless section 9.06(b) of this agreement applies, you

acknowledge and agree that nothing in this agreement will be

construed as conferring fiduciary status upon us. We will not be

required to perform any additional services unless specifically

agreed to under the terms and conditions of this agreement, or as

required under the Code and the regulations promulgated

thereunder with respect to Roth IRAs. You agree to indemnify and

hold us harmless for any and all claims, actions, proceedings,

damages, judgments, liabilities, costs, and expenses, including

attorney’s fees arising from or in connection with this agreement.

To the extent written instructions or notices are required under this

agreement, we may accept or provide such information in any

other form permitted by the Code or applicable regulations

including, but not limited to, electronic communication.

9.04 Disclosure of Account Information – We may use agents and/or

subcontractors to assist in administering your Roth IRA. We may

release nonpublic personal information regarding your Roth IRA to

such providers as necessary to provide the products and services

made available under this agreement, and to evaluate our business

operations and analyze potential product, service, or process

improvements.

9.05 Service Fees – We have the right to charge an annual service fee or

other designated fees (e.g., a transfer, rollover, or termination fee)

for maintaining your Roth IRA. In addition, we have the right to be

reimbursed for all reasonable expenses, including legal expenses,

we incur in connection with the administration of your Roth IRA.

We may charge you separately for any fees or expenses, or we may

deduct the amount of the fees or expenses from the assets in your

Roth IRA at our discretion. We reserve the right to charge any

additional fee after giving you 30 days’ notice. Fees such as

subtransfer agent fees or commissions may be paid to us by third

parties for assistance in performing certain transactions with

respect to this Roth IRA.

Any brokerage commissions attributable to the assets in your Roth

IRA will be charged to your Roth IRA. You cannot reimburse your

Roth IRA for those commissions.

9.06 Investment of Amounts in the Roth IRA –

a. Grantor Management of Investment. Unless the Roth IRA or a

portion of the Roth IRA is a managed Roth IRA, you have

exclusive responsibility for and control over the investment of

the assets of your Roth IRA. All transactions will be subject to

any and all restrictions or limitations, direct or indirect, that are

imposed by our charter, articles of incorporation, or bylaws; any

and all applicable federal and state laws and regulations; the

rules, regulations, customs, and usages of any exchange, market,

or clearing house where the transaction is executed; our policies

and practices; and this agreement. After your death, your

beneficiaries will have the right to direct the investment of your

Roth IRA assets, subject to the same conditions that applied to

you during your lifetime under this agreement (including,

without limitation, section 9.03 of this article). We will have no

discretion to direct any investment in your Roth IRA. We assume

no responsibility for rendering investment advice with respect

to your Roth IRA, nor will we offer any opinion or judgment to

you on matters concerning the value or suitability of any

investment or proposed investment for your Roth IRA. In the

absence of instructions from you, or if your instructions are not

in a form acceptable to us, we will have the right to hold any

uninvested amounts in cash, and we will have no responsibility

to invest uninvested cash unless and until directed by you. We

will not exercise the voting rights and other shareholder rights

with respect to investments in your Roth IRA unless you provide

timely written directions acceptable to us.

You will select the investment for your Roth IRA assets from

those investments that we are authorized by our charter,

articles of incorporation, or bylaws to offer and do in fact offer

for investment in Roth IRAs (e.g., term share accounts, passbook

accounts, certificates of deposit, money market accounts). We

may, in our sole discretion, make available to you, additional

investment offerings, that will be limited to publicly-traded

securities, mutual funds, money market instruments, and other

investments that are obtainable by us and that we are capable

of holding in the ordinary course of our business.

b. Trustee Management of Investment. If any portion of this Roth

IRA is a managed Roth IRA, as indicated on the application or

any other supporting documentation, we will manage the

investment of the applicable Roth IRA assets. Accordingly, we

can manage, sell, contract to sell, grant, or exercise options to

purchase, convey, exchange, transfer, abandon, improve, repair,

insure, lease for any term, and otherwise deal with all property,

real or personal, in your Roth IRA in such manner, for such prices

and on such terms and conditions as we will decide.

We will have the power to do any of the following as we deem

necessary or advisable.

1. To invest your Roth IRA assets in a single trust fund, and to

collect the income without distinction between principal

and income

2. To invest your Roth IRA assets in a common trust fund or

common investment fund within the meaning of Code

section 408(a)(5)

3. To invest your Roth IRA assets into savings instruments that

we offer

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4. To invest your Roth IRA assets in any other type of investment

permitted by law, including, but not limited to, common or

preferred stock, open- or closed-end mutual funds, bonds,

notes, debentures, options, U.S. Treasury bills, commercial

paper, or real estate

5. To hold any securities or other property under this

agreement in our own name, in the name of a nominee, or

in bearer form

6. To make, execute, acknowledge, and deliver any and all

documents of transfer and conveyance (including documents

for the transfer and conveyance of real estate), and any and

all instruments that may be necessary or appropriate to

carry out our powers

7. To employ suitable agents, attorneys, or other persons

8. To enter into lawsuits or settle any claims concerning the

assets in your Roth IRA, and to be reimbursed for any

expenses or damages from you or your Roth IRA assets

9. To exercise the voting rights and other shareholder rights

with respect to securities in your Roth IRA, provided,

however, that we reserve the right to enter into a separate

agreement with you governing the exercise of voting and

other shareholder rights

10. To perform any and all acts that we deem necessary or

appropriate for the proper administration of your Roth IRA

All of the foregoing notwithstanding, our powers will be subject to

any and all restrictions or limitations, direct or indirect, that are

imposed by our charter, articles of incorporation, or bylaws; any

and all applicable federal and state laws and regulations; the rules,

regulations, customs, and usages of any exchange, market, or

clearing house where the transaction is executed; our policies and

practices; and this agreement.

9.07 Beneficiaries – If you die before you receive all of the amounts in

your Roth IRA, payments from your Roth IRA will be made to your

beneficiaries. We have no obligation to pay to your beneficiaries

until such time we are notified of your death by receiving a valid

death certificate.

You may designate one or more persons or entities as beneficiary

of your Roth IRA. This designation can only be made on a form

provided by or acceptable to us, and it will only be effective when

it is filed with us during your lifetime. Each beneficiary designation

you file with us will cancel all previous designations. The consent of

your beneficiaries will not be required for you to revoke a

beneficiary designation. If you have designated both primary and

contingent beneficiaries and no primary beneficiary survives you,

the contingent beneficiaries will acquire the designated share of

your Roth IRA. If you do not designate a beneficiary or if all of your

primary and contingent beneficiaries predecease you, your estate

will be the beneficiary.

If your surviving spouse is the designated beneficiary, your spouse

may elect to treat your Roth IRA as his or her own Roth IRA, and

would not be subject to the required minimum distribution rules.

Your surviving spouse will also be entitled to such additional

beneficiary payment options as are granted under the Code or

applicable regulations.

We may allow, if permitted by state law, an original Roth IRA

beneficiary (the beneficiary who is entitled to receive distributions

from an inherited Roth IRA at the time of your death) to name

successor beneficiaries for the inherited Roth IRA. This designation

can only be made on a form provided by or acceptable to us, and it

will only be effective when it is filed with us during the original Roth

IRA beneficiary’s lifetime. Each beneficiary designation form that

the original Roth IRA beneficiary files with us will cancel all previous

designations. The consent of a successor beneficiary will not be

required for the original Roth IRA beneficiary to revoke a successor

beneficiary designation. If the original Roth IRA beneficiary does not

designate a successor beneficiary, his or her estate will be the

successor beneficiary. In no event will the successor beneficiary be

able to extend the distribution period beyond that required for the

original Roth IRA beneficiary.

If we so choose, for any reason (e.g., due to limitations of our

charter or bylaws), we may require that a beneficiary of a deceased

Roth IRA owner take total distribution of all Roth IRA assets by

December 31 of the year following the year of death.

9.08 Termination of Agreement, Resignation, or Removal of Trustee –

Either party may terminate this agreement at any time by giving

written notice to the other. We can resign as trustee at any time

effective 30 days after we send written notice of our resignation to

you. Upon receipt of that notice, you must make arrangements to

transfer your Roth IRA to another financial organization. If you do

not complete a transfer of your Roth IRA within 30 days from the

date we send the notice to you, we have the right to transfer your

Roth IRA assets to a successor Roth IRA trustee or custodian that we

choose in our sole discretion, or we may pay your Roth IRA to you

in a single sum. We will not be liable for any actions or failures to

act on the part of any successor trustee or custodian, nor for any

tax consequences you may incur that result from the transfer or

distribution of your assets pursuant to this section.

If this agreement is terminated, we may charge to your Roth IRA a

reasonable amount of money that we believe is necessary to cover

any associated costs, including but not limited to one or more of the

following.

• Any fees, expenses, or taxes chargeable against your Roth IRA

• Any penalties or surrender charges associated with the early

withdrawal of any savings instrument or other investment in

your Roth IRA

If we are a nonbank trustee required to comply with Regulations

section 1.408-2(e) and we fail to do so or we are not keeping the

records, making the returns, or sending the statements as are

required by forms or regulations, the IRS may require us to

substitute another trustee or custodian.

We may establish a policy requiring distribution of the entire

balance of your Roth IRA to you in cash or property if the balance

of your Roth IRA drops below the minimum balance required under

the applicable investment or policy established.

9.09 Successor Trustee – If our organization changes its name,

reorganizes, merges with another organization (or comes under the

control of any federal or state agency), or if our entire organization

(or any portion that includes your Roth IRA) is bought by another

organization, that organization (or agency) will automatically

become the trustee or custodian of your Roth IRA, but only if it is

the type of organization authorized to serve as a Roth IRA trustee

or custodian.

9.10 Amendments – We have the right to amend this agreement at any

time. Any amendment we make to comply with the Code and

related regulations does not require your consent. You will be

deemed to have consented to any other amendment unless, within

30 days from the date we send the amendment, you notify us in

writing that you do not consent.

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9.11 Withdrawals or Transfers – All requests for withdrawal or transfer

will be in writing on a form provided by or acceptable to us. The

method of distribution must be specified in writing or in any other

method acceptable to us. The tax identification number of the

recipient must be provided to us before we are obligated to make

a distribution. Withdrawals will be subject to all applicable tax and

other laws and regulations, including but not limited to possible

early distribution penalty taxes, surrender charges, and withholding

requirements.

You are not required to take a distribution from your Roth IRA at

age 70½. At your death, however, your beneficiaries must begin

taking distributions in accordance with Article V and section 9.07 of

this article. We will make no distributions to you from your Roth IRA

until you provide us with a written request for a distribution on a

form provided by or acceptable to us.

9.12 Transfers From Other Plans – We can receive amounts transferred

to this Roth IRA from the trustee or custodian of another Roth IRA

as permitted by the Code. In addition, we can accept rollovers of

eligible rollover distributions from employer-sponsored retirement

plans as permitted by the Code. We reserve the right not to accept

any transfer.

9.13 Liquidation of Assets – We have the right to liquidate assets in your

Roth IRA if necessary to make distributions or to pay fees, expenses,

taxes, penalties, or surrender charges properly chargeable against

your Roth IRA. If you fail to direct us as to which assets to liquidate,

we will decide, in our complete and sole discretion, and you agree

to not hold us liable for any adverse consequences that result from

our decision.

9.14 Restrictions on the Fund – Neither you nor any beneficiary may

sell, transfer, or pledge any interest in your Roth IRA in any manner

whatsoever, except as provided by law or this agreement.

The assets in your Roth IRA will not be responsible for the debts,

contracts, or torts of any person entitled to distributions under this

agreement.

9.15 What Law Applies – This agreement is subject to all applicable

federal and state laws and regulations. If it is necessary to apply any

state law to interpret and administer this agreement, the law of our

domicile will govern.

If any part of this agreement is held to be illegal or invalid, the

remaining parts will not be affected. Neither your nor our failure to

enforce at any time or for any period of time any of the provisions

of this agreement will be construed as a waiver of such provisions,

or your right or our right thereafter to enforce each and every such

provision.

GENERAL INSTRUCTIONS

Section references are to the Internal Revenue Code unless otherwise noted.

PURPOSE OF FORM

Form 5305-R is a model trust account agreement that meets the

requirements of section 408A and has been pre-approved by the IRS. A

Roth individual retirement account (Roth IRA) is established after the form

is fully executed by both the individual (grantor) and the trustee. This

account must be created in the United States for the exclusive benefit of

the grantor and his or her beneficiaries.

Do not file Form 5305-R with the IRS. Instead, keep it with your records.

Unlike contributions to Traditional individual retirement arrangements,

contributions to a Roth IRA are not deductible from the grantor’s gross

income; and distributions after 5 years that are made when the grantor is

59½ years of age or older or on account of death, disability, or the

purchase of a home by a first-time homebuyer (limited to $10,000), are

not includible in gross income. For more information on Roth IRAs,

including the required disclosures the trustee must give the grantor, see

Pub. 590, Individual Retirement Arrangements (IRAs).

DEFINITIONS

IRA Conversion Contributions – IRA conversion contributions are amounts

rolled over, transferred, or considered transferred from a nonRoth IRA to

a Roth IRA. A nonRoth IRA is an individual retirement account or annuity

described in section 408(a) or 408(b), other than a Roth IRA.

Trustee – The trustee must be a bank or savings and loan association, as

defined in section 408(n), or any person who has the approval of the IRS

to act as trustee.

Grantor – The grantor is the person who establishes the trust account.

SPECIFIC INSTRUCTIONS

Article I – The grantor may be subject to a 6% tax on excess contributions

if (1) contributions to other individual retirement arrangements of the

grantor have been made for the same tax year, (2) the grantor’s adjusted

gross income exceeds the applicable limits in Article II for the tax year, or

(3) the grantor’s and spouse’s compensation is less than the amount

contributed by or on behalf of them for the tax year. The grantor should

see the disclosure statement or Pub. 590 for more information.

Article V – This article describes how distributions will be made from the

Roth IRA after the grantor’s death. Elections made pursuant to this article

should be reviewed periodically to ensure they correspond to the

grantor’s intent. Under paragraph 3 of Article V, the grantor’s spouse is

treated as the owner of the Roth IRA upon the death of the grantor, rather

than as the beneficiary. If the spouse is to be treated as the beneficiary

and not the owner, an overriding provision should be added to Article IX.

Article IX – Article IX and any that follow it may incorporate additional

provisions that are agreed to by the grantor and trustee to complete the

agreement. They may include, for example, definitions, investment

powers, voting rights, exculpatory provisions, amendment and termination,

removal of the trustee, trustee’s fees, state law requirements, beginning

date of distributions, accepting only cash, treatment of excess

contributions, prohibited transactions with the grantor, etc. Attach

additional pages if necessary.

Page 7 of 13

RIGHT TO REVOKE YOUR ROTH IRA

You have the right to revoke your Roth IRA within seven days of the

receipt of the disclosure statement. If revoked, you are entitled to a full

return of the contribution you made to your Roth IRA. The amount

returned to you would not include an adjustment for such items as sales

commissions, administrative expenses, or fluctuation in market value. You

may make this revocation only by mailing or delivering a written notice to

the trustee at the address listed on the application.

If you send your notice by first class mail, your revocation will be deemed

mailed as of the postmark date.

If you have any questions about the procedure for revoking your Roth IRA,

please call the trustee at the telephone number listed on the application.

REQUIREMENTS OF A ROTH IRA

A. Cash Contributions – Your contribution must be in cash, unless it is a

rollover or conversion contribution.

B. Maximum Contribution – The total amount you may contribute to a

Roth IRA for any taxable year cannot exceed the lesser of 100 percent

of your compensation or $5,500 for 2015 and 2016, with possible cost-

of-living adjustments each year thereafter. If you also maintain a

Traditional IRA (i.e., an IRA subject to the limits of Internal Revenue

Code Sections (IRC Secs.) 408(a) or 408(b)), the maximum contribution

to your Roth IRAs is reduced by any contributions you make to your

Traditional IRAs. Your total annual contribution to all Roth IRAs and

Traditional IRAs cannot exceed the lesser of the dollar amounts

described above or 100 percent of your compensation.

Your Roth IRA contribution is further limited if your modified adjusted

gross income (MAGI) equals or exceeds $183,000 (for 2015) or

$184,000 (for 2016) if you are a married individual filing a joint income

tax return, or equals or exceeds $116,000 (for 2015) or $117,000 (for

2016) if you are a single individual. Married individuals filing a joint

income tax return with MAGI equaling or exceeding $193,000 (for

2015) or $194,000 (for 2016) may not fund a Roth IRA. Single

individuals with MAGI equaling or exceeding $131,000 (for 2015) or

$132,000 (for 2016) may not fund a Roth IRA. Married individuals filing

a separate income tax return with MAGI equaling or exceeding $10,000

may not fund a Roth IRA. The MAGI limits described above are subject

to cost-of-living increases for tax years beginning after 2016.

If you are married filing a joint income tax return and your MAGI is

between the applicable MAGI phase-out range for the year, your

maximum Roth IRA contribution is determined as follows. (1) Begin

with the appropriate MAGI phase-out maximum for the applicable year

and subtract your MAGI; (2) divide this total by the difference between

the phase-out range maximum and minimum; and (3) multiply this

number by the maximum allowable contribution for the applicable

year, including catch-up contributions if you are age 50 or older. For

example, if you are age 30 with MAGI of MAGI of $189,000, your

maximum Roth IRA contribution for 2016 is $2,750 ([$194,000 minus

$189,000] divided by $10,000 and multiplied by $5,500).

If you are single and your MAGI is between the applicable MAGI phase-

out for the year, your maximum Roth IRA contribution is determined

as follows. (1) Begin with the appropriate MAGI phase-out maximum

for the applicable year and subtract your MAGI; (2) divide this total by

the difference between the phase-out range maximum and minimum;

and (3) multiply this number by the maximum allowable contribution

for the applicable year, including catch-up contributions if you are age

50 or older. For example, if you are age 30 with MAGI of $120,000,

your maximum Roth IRA contribution for 2016 is $4,400 ([$132,000

minus $120,000] divided by $15,000 and multiplied by $5,500).

Contribution Eligibility –

You are eligible to make a regular contribution

to your Roth IRA, regardless of your age, if you have compensation and

your MAGI is below the maximum threshold. Your Roth IRA contribution

is not limited by your participation in an employer-sponsored

retirement plan, other than a Traditional IRA.

D. Catch-Up Contributions – If you are age 50 or older by the close of the

taxable year, you may make an additional contribution to your Roth

IRA. The maximum additional contribution is $1,000 per year.

E. Nonforfeitability – Your interest in your Roth IRA is nonforfeitable.

F. Eligible Trustees – The trustee of your Roth IRA must be a bank, savings

and loan association, credit union, or a person or entity approved by

the Secretary of the Treasury.

Commingling Assets –

The assets of your Roth IRA cannot be

commingled with other property except in a common trust fund or

common investment fund.

H. Life Insurance – No portion of your Roth IRA may be invested in life

insurance contracts.

I. Collectibles – You may not invest the assets of your Roth IRA in

collectibles (within the meaning of IRC Sec. 408(m)). A collectible is

defined as any work of art, rug or antique, metal or gem, stamp or coin,

alcoholic beverage, or other tangible personal property specified by

the Internal Revenue Service (IRS). However, specially minted United

States gold and silver coins, and certain state-issued coins are

permissible investments. Platinum coins and certain gold, silver,

platinum, or palladium bullion (as described in IRC Sec. 408(m)(3)) are

also permitted as Roth IRA investments.

J. Beneficiary Payouts – Your designated beneficiary is determined

based on the beneficiaries designated as of the date of your death,

who remain your beneficiaries as of September 30 of the year following

the year of your death. The entire amount remaining in your account

will, at the election of your designated beneficiaries, either

1. be distributed by December 31 of the year containing the fifth

anniversary of your death, or

2. be distributed over the remaining life expectancy of your designated

beneficiaries.

If your spouse is your sole designated beneficiary, he or she must elect

either option (1) or (2) by the earlier of December 31 of the year

containing the fifth anniversary of your death, or December 31 of the

year life expectancy payments would be required to begin. Your

designated beneficiaries, other than a spouse who is the sole designated

beneficiary, must elect either option (1) or (2) by December 31 of the

year following the year of your death. If no election is made,

distribution will be calculated in accordance with option (2). In the case

of distributions under option (2), distributions must commence by

December 31 of the year following the year of your death. Generally, if

your spouse is the designated beneficiary, distributions need not

commence until December 31 of the year you would have attained age

70½, if later. If a beneficiary other than a person or qualified trust as

defined in the Treasury Regulations is named, you will be treated as

having no designated beneficiary of your Roth IRA for purposes of

determining the distribution period. If there is no designated beneficiary

of your Roth IRA, the entire Roth IRA must be distributed by December

31 of the year containing the fifth anniversary of your death.

DISCLOSURE STATEMENT

Page 8 of 13

A spouse who is the sole designated beneficiary of your entire Roth IRA

will be deemed to elect to treat your Roth IRA as his or her own by

either (1) making contributions to your Roth IRA or (2) failing to timely

remove a required minimum distribution from your Roth IRA.

Regardless of whether or not the spouse is the sole designated

beneficiary of your Roth IRA, a spouse beneficiary may roll over his or

her share of the assets to his or her own Roth IRA.

If we so choose, for any reason (e.g., due to limitations of our charter

or bylaws), we may require that a beneficiary of a deceased Roth IRA

owner take total distribution of all Roth IRA assets by December 31 of

the year following the year of death.

If your beneficiary fails to remove a required minimum distribution

after your death, an additional penalty tax of 50 percent is imposed on

the amount of the required minimum distribution that should have

been taken but was not. Your beneficiary must file IRS Form 5329 along

with his or her income tax return to report and remit any additional

taxes to the IRS.

INCOME TAX CONSEQUENCES OF ESTABLISHING A ROTH IRA

A. Contributions Not Deducted – No deduction is allowed for Roth IRA

contributions, including transfers, rollovers, and conversion

contributions.

B. Contribution Deadline – The deadline for making a Roth IRA

contribution is your tax return due date (not including extensions). You

may designate a contribution as a contribution for the preceding

taxable year in a manner acceptable to us. For example, if you are a

calendar-year taxpayer and you make your Roth IRA contribution on or

before your tax filing deadline, your contribution is considered to have

been made for the previous tax year if you designate it as such.

If you are a member of the Armed Forces serving in a combat zone,

hazardous duty area, or contingency operation, you may have an

extended contribution deadline of 180 days after the last day served in

the area. In addition, your contribution deadline for a particular tax

year is also extended by the number of days that remained to file that

year’s tax return as of the date you entered the combat zone. This

additional extension to make your Roth IRA contribution cannot

exceed the number of days between January 1 and your tax filing

deadline, not including extensions.

C. Tax Credit for Contributions – You may be eligible to receive a tax

credit for your Roth IRA contributions. This credit may not exceed

$1,000 in a given year. You may be eligible for this tax credit if you are

• age 18 or older as of the close of the taxable year,

• not a dependent of another taxpayer, and

• not a full-time student.

The credit is based upon your income (see chart below), and will range

from 0 to 50 percent of eligible contributions. In order to determine

the amount of your contributions, add all of the contributions made to

your Roth IRA and reduce these contributions by any distributions that

you have taken during the testing period. The testing period begins

two years prior to the year for which the credit is sought and ends on

the tax return due date (including extensions) for the year for which

the credit is sought. In order to determine your tax credit, multiply the

applicable percentage from the chart below by the amount of your

contributions that do not exceed $2,000.

2016 Adjusted Gross Income*

Joint Head of a All Other

Applicable

Return Household Cases

Percentage

$1 – 37,000 $1 – 27,750 $1 – 18,500 50

$37,001 – 40,000 $27,751 – 30,000 $18,501 – 20,000 20

$40,001 – 61,500 $30,001 – 46,125 $20,001 – 30,750 10

Over $61,500 Over $46,125 Over $30,750 0

*Adjusted gross income (AGI) includes foreign earned income and

income from Guam, America Samoa, North Mariana Islands, and Puerto

Rico. AGI limits are subject to cost-of-living adjustments each year.

D. Excess Contributions – An excess contribution is any amount that is

contributed to your Roth IRA that exceeds the amount that you are

eligible to contribute. If the excess is not corrected timely, an additional

penalty tax of six percent will be imposed upon the excess amount. The

procedure for correcting an excess is determined by the timeliness of

the correction as identified below.

1. Removal Before Your Tax Filing Deadline. An excess contribution

may be corrected by withdrawing the excess amount, along with

the earnings attributable to the excess, before your tax filing

deadline, including extensions, for the year for which the excess

contribution was made. An excess withdrawn under this method is

not taxable to you, but you must include the earnings attributable

to the excess in your taxable income in the year in which the

contribution was made. The six percent excess contribution penalty

tax will be avoided.

2. Removal After Your Tax Filing Deadline. If you are correcting an

excess contribution after your tax filing deadline, including

extensions, remove only the amount of the excess contribution.

The six percent excess contribution penalty tax will be imposed on

the excess contribution for each year it remains in the Roth IRA. An

excess withdrawal under this method is not taxable to you.

3. Carry Forward to a Subsequent Year. If you do not withdraw the

excess contribution, you may carry forward the contribution for a

subsequent tax year. To do so, you under-contribute for that tax

year and carry the excess contribution amount forward to that year

on your tax return. The six percent excess contribution penalty tax

will be imposed on the excess amount for each year that it remains

as an excess contribution at the end of the year.

You must file IRS Form 5329 along with your income tax return to

report and remit any additional taxes to the IRS.

E. Tax-Deferred Earnings – The investment earnings of your Roth IRA are

not subject to federal income tax as they accumulate in your Roth IRA.

In addition, distributions of your Roth IRA earnings will be free from

federal income tax if you take a qualified distribution, as described

below.

F. Taxation of Distributions – The taxation of Roth IRA distributions

depends on whether the distribution is a qualified distribution or a

nonqualified distribution.

1. Qualified Distributions. Qualified distributions from your Roth IRA

(both the contributions and earnings) are not included in your

income. A qualified distribution is a distribution that is made after

the expiration of the five-year period beginning January 1 of the

first year for which you made a contribution to any Roth IRA

(including a conversion from a Traditional IRA), and is made on

account of one of the following events.

• Attainment of age 59½

• Disability

• First-time homebuyer purchase

• Death

Page 9 of 13

For example, if you made a contribution to your Roth IRA for 2007,

the five-year period for determining whether a distribution is a

qualified distribution is satisfied as of January 1, 2012.

2. Nonqualified Distributions. If you do not meet the requirements

for a qualified distribution, any earnings you withdraw from your

Roth IRA will be included in your gross income and, if you are under

age 59½, may be subject to an early distribution penalty tax.

However, when you take a distribution, the amounts you

contributed annually to any Roth IRA and any military death

gratuity or Servicemembers’ Group Life Insurance (SGLI) payments

that you rolled over to a Roth IRA, will be deemed to be removed

first, followed by conversion and employer-sponsored retirement

plan rollover contributions made to any Roth IRA on a first-in, first-

out basis. Therefore, your nonqualified distributions will not be

taxable to you until your withdrawals exceed the amount of your

annual contributions, rollovers of your military death gratuity or

SGLI payments, and your conversions and employer-sponsored

retirement plan rollovers.

Income Tax Withholding

– Any nonqualified withdrawal of earnings

from your Roth IRA may be subject to federal income tax withholding.

You may, however, elect not to have withholding apply to your Roth

IRA withdrawal. If withholding is applied to your withdrawal, not less

than 10 percent of the amount withdrawn must be withheld.

Early Distribution Penalty Tax

– If you are under age 59½ and receive a

nonqualified Roth IRA distribution, an additional early distribution

penalty tax of 10 percent generally will apply to the amount includible

in income in the year of the distribution. If you are under age 59½ and

receive a distribution of conversion amounts or employer-sponsored

retirement plan rollover amounts within the five-year period beginning

with the year in which the conversion or employer-sponsored

retirement plan rollover occurred, an additional early distribution

penalty tax of 10 percent generally will apply to the amount of the

distribution. The additional early distribution penalty tax of 10 percent

generally will not apply if one of the following exceptions apply.

1) Death. After your death, payments made to your beneficiary are not

subject to the 10 percent early distribution penalty tax. 2) Disability. If

you are disabled at the time of distribution, you are not subject to the

additional 10 percent early distribution penalty tax. In order to be

disabled, a physician must determine that your impairment can be

expected to result in death or to be of long, continued, and indefinite

duration. 3) Substantially equal periodic payments. You are not

subject to the additional 10 percent early distribution penalty tax if you

are taking a series of substantially equal periodic payments (at least

annual payments) over your life expectancy or the joint life expectancy

of you and your beneficiary. You must continue these payments for the

longer of five years or until you reach age 59½. 4) Unreimbursed

medical expenses. If you take payments to pay for unreimbursed

medical expenses exceeding 10 percent of your adjusted gross income,

you will not be subject to the 10 percent early distribution penalty tax.

The medical expenses may be for you, your spouse, or any dependent

listed on your tax return. 5) Health insurance premiums. If you are

unemployed and have received unemployment compensation for 12

consecutive weeks under a federal or state program, you may take

payments from your Roth IRA to pay for health insurance premiums

without incurring the 10 percent early distribution penalty tax.

6) Higher education expenses. Payments taken for certain qualified

higher education expenses for you, your spouse, or the children or

grandchildren of you or your spouse, will not be subject to the 10

percent early distribution penalty tax. 7) First-time homebuyer. You

may take payments from your Roth IRA to use toward qualified

acquisition costs of buying or building a principle residence. The

amount you may take for this reason may not exceed a lifetime

maximum of $10,000. The payment must be used for qualified

acquisition costs within 120 days of receiving the distribution. 8) IRS

levy. Payments from your Roth IRA made to the U.S. government in

response to a federal tax levy are not subject to the 10 percent early

distribution penalty tax. 9) Qualified reservist distributions. If you are

a qualified reservist member called to active duty for more than 179

days or an indefinite period, the payments you take from your Roth IRA

during the active duty period are not subject to the 10 percent early

distribution penalty tax.

You must file IRS Form 5329 along with your income tax return to the

IRS to report and remit any additional taxes or to claim a penalty tax

exception.

I. Required Minimum Distributions – You are not required to take

distributions from your Roth IRA at age 70½ (as required for Traditional

and savings incentive match plan for employees of small employers

(SIMPLE) IRAs). However, your beneficiaries generally are required to

take distributions from your Roth IRA after your death. See the section

titled Beneficiary Payouts in this disclosure statement regarding

beneficiaries’ required minimum distributions.

J. Rollovers and Conversions – Your Roth IRA may be rolled over to

another Roth IRA of yours, may receive rollover contributions, or may

receive conversion contributions, provided that all of the applicable

rollover or conversion rules are followed. Rollover is a term used to

describe a movement of cash or other property to your Roth IRA from

another Roth IRA, or from your employer’s qualified retirement plan,

403(a) annuity, 403(b) tax-sheltered annuity, 457(b) eligible governmental

deferred compensation plan, or federal Thrift Savings Plan. Conversion is

a term used to describe the movement of Traditional IRA or SIMPLE IRA

assets to a Roth IRA. A conversion generally is a taxable event. The

general rollover and conversion rules are summarized below. These

transactions are often complex. If you have any questions regarding a

rollover or conversion, please see a competent tax advisor.

1. Roth IRA-to-Roth IRA Rollovers. Assets distributed from your Roth

IRA may be rolled over to the same Roth IRA or another Roth IRA of

yours if the requirements of IRC Sec. 408(d)(3) are met. A proper

Roth IRA-to-Roth IRA rollover is completed if all or part of the

distribution is rolled over not later than 60 days after the distribution

is received. In the case of a distribution for a first-time homebuyer

where there was a delay or cancellation of the purchase, the 60-day

rollover period may be extended to 120 days. Roth IRA assets may

not be rolled over to other types of IRAs (e.g., Traditional IRA,

SIMPLE IRA), or employer-sponsored retirement plans.

You are permitted to roll over only one distribution from an IRA

(Traditional, Roth, or SIMPLE) in a 12-month period, regardless of

the number of IRAs you own. A distribution may be rolled over to

the same IRA or to another IRA that is eligible to receive the

rollover. For more information on rollover limitations, you may

wish to obtain IRS Publication 590-B, Distributions from Individual

Retirement Arrangements (IRAs), from the IRS or refer to the IRS

website at www.irs.gov.

2. Traditional IRA-to-Roth IRA Conversions. If you convert to a Roth

IRA, the amount of the conversion from your Traditional IRA to your

Roth IRA will be treated as a distribution for income tax purposes,

and is includible in your gross income (except for any nondeductible

contributions). Although the conversion amount generally is

included in income, the 10 percent early distribution penalty tax

will not apply to conversions from a Traditional IRA to a Roth IRA,

regardless of whether you qualify for any exceptions to the 10

percent early distribution penalty tax. If you are age 70½ or older,

you must remove your required minimum distribution before

converting your Traditional IRA.

Page 10 of 13

3. SIMPLE IRA-to-Roth IRA Conversions. You are eligible to convert

all or any portion of your existing SIMPLE IRA into your Roth IRA,

provided two years have passed since you first participated in a

SIMPLE IRA plan sponsored by your employer. The amount of the

conversion from your SIMPLE IRA to your Roth IRA will be treated

as a distribution for income tax purposes and is includible in your

gross income. Although the conversion amount generally is included

in income, the 10 percent early distribution penalty tax will not

apply to conversions from a SIMPLE IRA to a Roth IRA, regardless of

whether you qualify for any exceptions to the 10 percent early

distribution penalty tax. If you are age 70½ or older you must

remove your required minimum distribution before converting

your SIMPLE IRA.

4. Rollovers of Roth Elective Deferrals. Roth elective deferrals

distributed from a 401(k) cash or deferred arrangement, 403(b) tax-

sheltered annuity, 457(b) eligible governmental deferred

compensation plan, or federal Thrift Savings Plan, may be rolled

into your Roth IRA.

5. Employer-Sponsored Retirement Plan-to-Roth IRA Rollovers. You

may roll over, directly or indirectly, any eligible rollover distribution

from an eligible employer-sponsored retirement plan to your Roth

IRA. An eligible rollover distribution is defined generally as any

distribution from a qualified retirement plan, 403(a) annuity, 403(b)

tax-sheltered annuity, 457(b) eligible governmental deferred

compensation plan, or federal Thrift Savings Plan unless it is a

required minimum distribution, hardship distribution, part of a

certain series of substantially equal periodic payments, corrective

distributions of excess contributions, excess deferrals, excess annual

additions and any income allocable to the excess, deemed loan

distribution, dividends on employer securities, or the cost of life

insurance coverage. If you are a spouse, nonspouse, or qualified

trust beneficiary who has inherited a qualified retirement plan,

403(a) annuity, 403(b) tax-sheltered annuity, or 457(b) eligible

governmental deferred compensation plan, you may be eligible to

directly roll over the assets to an inherited Roth IRA. The inherited

Roth IRA is subject to the beneficiary distribution requirements.

Although the rollover amount generally is included in income, the

10 percent early distribution penalty tax will not apply to rollovers

from eligible employer-sponsored retirement plans to a Roth IRA or

inherited Roth IRA, regardless of whether you qualify for any

exceptions to the 10 percent early distribution penalty tax.

6. Beneficiary Rollovers From 401(k), 403(b), or 457(b) Eligible

Governmental Plans Containing Roth Elective Deferrals. If you are

a spouse, nonspouse, or qualified trust beneficiary of a deceased

401(k), 403(b), or 457(b) eligible governmental deferred

compensation plan participant who had made Roth elective

deferrals to the plan, you may directly roll over the Roth elective

deferrals and their earnings to an inherited Roth IRA. The Roth IRA

must be maintained as an inherited Roth IRA, subject to the

beneficiary distribution requirements.

7. Rollovers of Military Death Benefits. If you receive or have

received a military death gratuity or a payment from the SGLI

program, you may be able to roll over the proceeds to your Roth

IRA. The rollover contribution amount is limited to the sum of the

death benefits or SGLI payment received, less any such amount that

was rolled over to a Coverdell education savings account. Proceeds

must be rolled over within one year of receipt of the gratuity or SGLI

payment for deaths occurring on or after June 17, 2008. Any

amount that is rolled over under this provision is considered

nontaxable basis in your Roth IRA.

8. Qualified HSA Funding Distribution. If you are eligible to contribute

to a health savings account (HSA), you may be eligible to take a one-

time tax-free qualified HSA funding distribution from your Roth IRA

and directly deposit it to your HSA. The amount of the qualified HSA

funding distribution may not exceed the maximum HSA contribution

limit in effect for the type of high deductible health plan coverage

(i.e., single or family coverage) that you have at the time of the

deposit, and counts toward your HSA contribution limit for that

year. For further detailed information, you may wish to obtain IRS

Publication 969, Health Savings Accounts and Other Tax-Favored

Health Plans.

9. Rollovers of Settlement Payments From Bankrupt Airlines. If

you are a qualified airline employee who has received a qualified

airline settlement payment from a commercial airline carrier

under the approval of an order of a federal bankruptcy court in a

case filed after September 11, 2001, and before January 1, 2007,

you are allowed to roll over any portion of the proceeds into your

Roth IRA within 180 days after receipt of such amount, or by a

later date if extended by federal law. For further detailed

information and effective dates you may obtain IRS Publication

590-A, Contributions to Individual Retirement Arrangements

(IRAs), from the IRS or refer to the IRS website at www.irs.gov.

10. Rollovers of Exxon Valdez Settlement Payments. If you receive a

qualified settlement payment from Exxon Valdez litigation, you may

roll over the amount of the settlement, up to $100,000, reduced by

the amount of any qualified Exxon Valdez settlement income

previously contributed to a Traditional or Roth IRA or eligible

retirement plan in prior taxable years. You will have until your tax

return due date (not including extensions) for the year in which the

qualified settlement income is received to make the rollover

contribution. To obtain more information on this type of rollover,

you may wish to visit the IRS website at www.irs.gov.

11. Written Election. At the time you make a rollover or conversion to

a Roth IRA, you must designate in writing to the trustee your

election to treat that contribution as a rollover or conversion. Once

made, the election is irrevocable.

K. Transfer Due to Divorce – If all or any part of your Roth IRA is awarded

to your spouse or former spouse in a divorce or legal separation

proceeding, the amount so awarded will be treated as the spouse’s

Roth IRA (and may be transferred pursuant to a court-approved

divorce decree or written legal separation agreement to another Roth

IRA of your spouse), and will not be considered a taxable distribution

to you. A transfer is a tax-free direct movement of cash and/or

property from one Roth IRA to another.

L. Recharacterizations – If you make a contribution to a Traditional IRA

and later recharacterize either all or a portion of the original

contribution to a Roth IRA along with net income attributable, you may

elect to treat the original contribution as having been made to the Roth

IRA. The same methodology applies when recharacterizing a

contribution from a Roth IRA to a Traditional IRA. If you have converted

from a Traditional IRA to a Roth IRA you may recharacterize the

conversion along with net income attributable back to a Traditional

IRA. If you have rolled over an eligible employer-sponsored retirement

plan to a Roth IRA, you may recharacterize the rollover amount along

with net income attributable to a Traditional IRA. The deadline for

completing a recharacterization is your tax filing deadline (including

any extensions) for the year for which the original contribution was

made or conversion or rollover completed.

Page 11 of 13

LIMITATIONS AND RESTRICTIONS

A. Spousal Roth IRA – If you are married and have compensation, you

may contribute to a Roth IRA established for the benefit of your

spouse, regardless of whether or not your spouse has compensation.

You must file a joint income tax return for the year for which the

contribution is made.

The amount you may contribute to your Roth IRA and your spouse’s

Roth IRA is the lesser of 100 percent of your combined eligible

compensation or $11,000 for 2015 and 2016. This amount may be

increased with cost-of-living adjustments each year. However, you may

not contribute more than the individual contribution limit to each Roth

IRA. Your contribution may be further limited if your MAGI falls within

the minimum and maximum thresholds.

If your spouse is age 50 or older by the close of the taxable year, and is

otherwise eligible, you may make an additional contribution to your

spouse’s Roth IRA. The maximum additional contribution is $1,000 per

year.

B. Gift Tax – Transfers of your Roth IRA assets to a beneficiary made

during your life and at your request may be subject to federal gift tax

under IRC Sec. 2501.

C. Special Tax Treatment – Capital gains treatment and 10-year income

averaging authorized by IRC Sec. 402 do not apply to Roth IRA

distributions.

D. Prohibited Transactions – If you or your beneficiary engage in a

prohibited transaction with your Roth IRA, as described in IRC Sec.

4975, your Roth IRA will lose its tax-deferred or tax-exempt status, and

you generally must include the value of the earnings in your account in

your gross income for that taxable year. The following transactions are

examples of prohibited transactions with your Roth IRA. (1) Taking a

loan from your Roth IRA (2) Buying property for personal use (present

or future) with Roth IRA assets (3) Receiving certain bonuses or

premiums because of your Roth IRA.

E. Pledging – If you pledge any portion of your Roth IRA as collateral for

a loan, the amount so pledged will be treated as a distribution and may

be included in your gross income for that year.

OTHER

A. IRS Plan Approval – The agreement used to establish this Roth IRA has

been approved by the IRS. The IRS approval is a determination only as

to form. It is not an endorsement of the plan in operation or of the

investments offered.

B. Additional Information – For further information on Roth IRAs, you

may wish to obtain IRS Publication 590-A, Contributions to Individual

Retirement Arrangements (IRAs), or Publication 590-B, Distributions

from Individual Retirement Arrangements (IRAs), by calling 1-800-TAX-

FORM, or by visiting www.irs.gov on the Internet.

Important Information About Procedures for Opening a New Account

–

To help the government fight the funding of terrorism and money

laundering activities, federal law requires all financial organizations to

obtain, verify, and record information that identifies each person who

opens an account. Therefore, when you open a Roth IRA, you are

required to provide your name, residential address, date of birth, and

identification number. We may require other information that will

allow us to identify you.

D. Qualified Reservist Distributions – If you are an eligible qualified

reservist who has taken penalty-free qualified reservist distributions

from your Roth IRA or retirement plan, you may recontribute those

amounts to a Roth IRA generally within a two-year period from your

date of return.

E. Qualified Charitable Distributions – If you are age 70½ or older, you

may take tax-free Roth IRA distributions of up to $100,000 per year and

have these distributions paid directly to certain charitable organizations.

Special tax rules may apply. For further detailed information and

effective dates you may obtain IRS Publication 590-B, Distributions

from Individual Retirement Arrangements (IRAs), from the IRS or refer

to the IRS website at www.irs.gov.

F. Disaster Related Relief – If you qualify (for example, you sustained an

economic loss due to, or are otherwise considered affected by, certain

IRS designated disasters), you may be eligible for favorable tax

treatment on distributions, rollovers, and other transactions involving

your Roth IRA. Qualified disaster relief may include penalty-tax free

early distributions made during specified timeframes for each disaster,

the ability to include distributions in your gross income ratably over

multiple years, the ability to roll over distributions to an eligible

retirement plan without regard to the 60-day rollover rule, and more.

For additional information on specific disasters, including a complete

listing of disaster areas, qualification requirements for relief, and

allowable disaster-related Roth IRA transactions, you may wish to

obtain IRS Publication 590-B, Distributions from Individual Retirement

Arrangements (IRAs), from the IRS or refer to the IRS website at

www.irs.gov.

Page 12 of 13

The term IRA will be used below to mean Traditional IRA, Roth IRA, and SIMPLE IRA, unless otherwise specified.

The financial organization should complete the financial disclosure using Method I, Method II, or Method III. If the growth of the IRA can reasonably be

projected, use either Method I or Method II. The account values projected using Method I or Method II must be reduced by all applicable fees and penalties.

If annual fees are assessed, such as an annual service fee, use Method II. If no projection of growth of the IRA can reasonably be shown, use Method III.

METHOD I Growth can be projected (Do not use Method I if an annual fee is charged. Instead, use Method II for financial projections.)

Your Age on Your Birth Date This Year _________ Length of Time Deposit (If applicable) ________________________

The charts below give projections of the value of your IRA by showing the amount available at the end of each year. These projections assume an

interest rate of .25%, compounded annually. If you have invested your IRA in a time deposit, a loss-of-earnings penalty may be charged against a

withdrawal before maturity. A transaction fee may also apply to your IRA.

The Regular Contribution chart assumes that an annual contribution of $1,000 is made on the first day of each year. The Rollover, Transfer, or

Conversion* chart assumes that a one-time deposit of $1,000 is made on the first day of the first year.

Indicate the projected account value for each of the years, taking into consideration any applicable loss of earnings penalty or other fees assessed if the

IRA owner received a distribution at the end of the year for which the projection is being made. First, circle the year-end projected IRA value that is

applicable for each of the first five years. Next, circle the applicable IRA value for the years in which the IRA owner will attain ages 60, 65, and 70.

FINANCIAL DISCLOSURE

REGULAR CONTRIBUTION

FINANCIAL PROJECTIONS WITH .25% RATE OF INTEREST

AMT. AFTER

NO. ACCOUNT 1 MO. 3 MO. 6 MO.

FEES AND

YRS VALUE PENALTY PENALTY PENALTY

PENALTIES

1 $1,002.50 $1,002.29 $1,001.87 $1,001.25

2 2,007.51 2,007.09 2,006.25 2,005.00

3 3,015.03 3,014.40 3,013.14 3,011.26

4 4,025.06 4,024.22 4,022.55 4,020.03

5 5,037.63 5,036.58 5,034.48 5,031.33

6 6,052.72 6,051.46 6,048.94 6,045.15

7 7,070.35 7,068.88 7,065.93 7,061.51

8 8,090.53 8,088.84 8,085.47 8,080.41

9 9,113.25 9,111.35 9,107.56 9,101.86

10 10,138.54 10,136.42 10,132.20 10,125.86

11 11,166.38 11,164.06 11,159.40 11,152.42

12 12,196.80 12,194.26 12,189.18 12,181.55

13 13,229.79 13,227.03 13,221.52 13,213.25

14 14,265.37 14,262.39 14,256.45 14,247.53

15 15,303.53 15,300.34 15,293.96 15,284.40

16 16,344.29 16,340.88 16,334.07 16,323.86

17 17,387.65 17,384.03 17,376.78 17,365.91

18 18,433.62 18,429.78 18,422.10 18,410.58

19 19,482.20 19,478.14 19,470.02 19,457.85

20 20,533.41 20,529.13 20,520.57 20,507.74

21 21,587.24 21,582.74 21,573.75 21,560.26

22 22,643.71 22,638.99 22,629.56 22,615.40

23 23,702.82 23,697.88 23,688.00 23,673.19

24 24,764.57 24,759.42 24,749.10 24,733.62

25 25,828.99 25,823.61 25,812.84 25,796.70

26 26,896.06 26,890.46 26,879.25 26,862.44

27 27,965.80 27,959.97 27,948.32 27,930.84

28 29,038.21 29,032.16 29,020.06 29,001.92

29 30,113.31 30,107.04 30,094.49 30,075.67

30 31,191.09 31,184.59 31,171.60 31,152.10

31 32,271.57 32,264.85 32,251.40 32,231.23

32 33,354.75 33,347.80 33,333.90 33,313.06

33 34,440.64 34,433.46 34,419.11 34,397.58

34 35,529.24 35,521.84 35,507.03 35,484.83

35 36,620.56 36,612.93 36,597.67 36,574.78

36 37,714.61 37,706.75 37,691.04 37,667.47

37 38,811.40 38,803.31 38,787.14 38,762.88

38 39,910.93 39,902.61 39,885.98 39,861.04

39 41,013.20 41,004.66 40,987.57 40,961.94

40 42,118.24 42,109.46 42,091.91 42,065.59

41 43,226.03 43,217.03 43,199.02 43,172.00

42 44,336.60 44,327.36 44,308.89 44,281.18

43 45,449.94 45,440.47 45,421.53 45,393.13

44 46,566.06 46,556.36 46,536.96 46,507.86

45 47,684.98 47,675.04 47,655.18 47,625.37

46 48,806.69 48,796.52 48,776.19 48,745.68

47 49,931.21 49,920.81 49,900.00 49,868.79

48 51,058.54 51,047.90 51,026.62 50,994.71

49 52,188.68 52,177.81 52,156.06 52,123.45

50 53,321.65 53,310.55 53,288.33 53,255.00

51 54,457.46 54,446.11 54,423.42 54,389.39

52 55,596.10 55,584.52 55,561.35 55,526.61

53 56,737.59 56,725.77 56,702.13 56,666.67

54 57,881.94 57,869.88 57,845.76 57,809.58

55 59,029.14 59,016.84 58,992.25 58,955.35

56 60,179.21 60,166.68 60,141.60 60,103.99

57 61,332.16 61,319.38 61,293.83 61,255.50

58 62,487.99 62,474.97 62,448.94 62,409.88

59 63,646.71 63,633.45 63,606.93 63,567.15

60 64,808.33 64,794.83 64,767.82 64,727.32

61 65,972.85 65,959.11 65,931.62 65,890.38

62 67,140.28 67,126.29 67,098.32 67,056.36

ADDITIONAL FINANCIAL DISCLOSURE

INFORMATION

The account values shown are projections based

on many assumptions. They are not guaranteed,

but depend upon many factors, including the

interest rates and terms of future funding

instruments.

We may charge you fees in connection with your

IRA. If we do not charge these fees now, we may

do so in the future after giving you notice. If you

do not pay these fees separately, they may be

paid from the assets of your IRA.

CURRENT FEES

_____________________ $ _______________

IRA

ROLLOVER, TRANSFER, OR CONVERSION*

FINANCIAL PROJECTIONS WITH .25% RATE OF INTEREST

AMT. AFTER

NO. ACCOUNT 1 MO. 3 MO. 6 MO.

FEES AND

YRS VALUE PENALTY PENALTY PENALTY

PENALTIES

1 $1,002.50 $1,002.29 $1,001.87 $1,001.25

2 1,005.01 1,004.80 1,004.38 1,003.75

3 1,007.52 1,007.31 1,006.89 1,006.26

4 1,010.04 1,009.83 1,009.41 1,008.78

5 1,012.56 1,012.35 1,011.93 1,011.30

6 1,015.09 1,014.88 1,014.46 1,013.83

7 1,017.63 1,017.42 1,017.00 1,016.36

8 1,020.18 1,019.96 1,019.54 1,018.90

9 1,022.73 1,022.51 1,022.09 1,021.45

10 1,025.28 1,025.07 1,024.64 1,024.00

11 1,027.85 1,027.63 1,027.20 1,026.56

12 1,030.42 1,030.20 1,029.77 1,029.13

13 1,032.99 1,032.78 1,032.35 1,031.70

14 1,035.57 1,035.36 1,034.93 1,034.28

15 1,038.16 1,037.95 1,037.51 1,036.87

16 1,040.76 1,040.54 1,040.11 1,039.46

17 1,043.36 1,043.14 1,042.71 1,042.06

18 1,045.97 1,045.75 1,045.32 1,044.66

19 1,048.58 1,048.37 1,047.93 1,047.27

20 1,051.21 1,050.99 1,050.55 1,049.89

21 1,053.83 1,053.61 1,053.17 1,052.52

22 1,056.47 1,056.25 1,055.81 1,055.15

23 1,059.11 1,058.89 1,058.45 1,057.79

24 1,061.76 1,061.54 1,061.09 1,060.43

25 1,064.41 1,064.19 1,063.75 1,063.08

26 1,067.07 1,066.85 1,066.41 1,065.74

27 1,069.74 1,069.52 1,069.07 1,068.40

28 1,072.41 1,072.19 1,071.74 1,071.07

29 1,075.10 1,074.87 1,074.42 1,073.75

30 1,077.78 1,077.56 1,077.11 1,076.44

31 1,080.48 1,080.25 1,079.80 1,079.13

32 1,083.18 1,082.95 1,082.50 1,081.82

33 1,085.89 1,085.66 1,085.21 1,084.53

34 1,088.60 1,088.37 1,087.92 1,087.24

35 1,091.32 1,091.10 1,090.64 1,089.96

36 1,094.05 1,093.82 1,093.37 1,092.68

37 1,096.79 1,096.56 1,096.10 1,095.42

38 1,099.53 1,099.30 1,098.84 1,098.15

39 1,102.28 1,102.05 1,101.59 1,100.90

40 1,105.03 1,104.80 1,104.34 1,103.65

41 1,107.80 1,107.56 1,107.10 1,106.41

42 1,110.57 1,110.33 1,109.87 1,109.18

43 1,113.34 1,113.11 1,112.65 1,111.95

44 1,116.12 1,115.89 1,115.43 1,114.73

45 1,118.92 1,118.68 1,118.22 1,117.52

46 1,121.71 1,121.48 1,121.01 1,120.31

47 1,124.52 1,124.28 1,123.81 1,123.11

48 1,127.33 1,127.09 1,126.62 1,125.92

49 1,130.15 1,129.91 1,129.44 1,128.73

50 1,132.97 1,132.74 1,132.26 1,131.56

51 1,135.80 1,135.57 1,135.09 1,134.38

52 1,138.64 1,138.41 1,137.93 1,137.22

53 1,141.49 1,141.25 1,140.78 1,140.06

54 1,144.34 1,144.11 1,143.63 1,142.91

55 1,147.20 1,146.97 1,146.49 1,145.77

56 1,150.07 1,149.83 1,149.35 1,148.64

57 1,152.95 1,152.71 1,152.23 1,151.51

58 1,155.83 1,155.59 1,155.11 1,154.39

59 1,158.72 1,158.48 1,158.00 1,157.27

60 1,161.62 1,161.37 1,160.89 1,160.16

61 1,164.52 1,164.28 1,163.79 1,163.07

62 1,167.43 1,167.19 1,166.70 1,165.97

*Conversion applies to Roth IRAs only

Page 13 of 13

METHOD III Growth cannot be projected

The value of your IRA will be dependent solely upon the performance of

any investment instrument used to fund your IRA. Therefore, no projection

of the growth of your IRA can reasonably be shown or guaranteed.

Terms and conditions of the IRA that affect your investment are listed

below.

INVESTMENT OPTIONS

Your IRA will be invested in products that we offer directly or those we

offer through a relationship with a registered securities broker-dealer.

FEES

There are certain fees and charges connected with your IRA investments.

These fees and charges may include the following.

• Sales Commissions • Set Up Fees

• Investment Management Fees • Annual Maintenance Fees

• Distribution Fees • Surrender or Termination Fees

To find out what fees apply, refer to the investment prospectus or contract.

There may be certain fees and charges connected with the IRA itself.

(Select and complete as applicable.)

Annual Service Fee $ _____________________________

Transfer Fee $ _____________________________

Rollover Fee $ _____________________________

Termination Fee $ _____________________________

Other (Explain) ______________________________

______________________________

We reserve the right to change any of the above fees after notice to you,

as provided in your IRA agreement.

EARNINGS

The method for computing and allocating annual earnings (e.g., interest,

dividends) on your IRA will differ based on the nature and issuer of the

investments chosen. Refer to the investment prospectus or contract for

the methods used for computing and allocating annual earnings.

OTHER

Other terms or conditions that apply to your IRA include the following.

____________________________________________________________

METHOD II Growth can be projected

The financial projections below show the amount that would be available

if you were to withdraw your IRA assets at the indicated times. These

projections are based on the following assumptions.

CONTRIBUTION (Select one)

Regular. An annual $1,000 deposit is made on the first day of

each year.

Rollover, Transfer, or Conversion.* A one-time $1,000 deposit is

made on the first day of the first year.

Your Age on Your Birth Date in Contribution Year ___________________

Investment Instrument _________________________________________

Length of Time Deposit ________________________________________

Rate of Interest _____________________________________________ %

Compounding Method _________________________________________

FINANCIAL PROJECTIONS

Number of Total Amount

Years in IRA Accumulation After Fees

Program of IRA Dollars and Penalties

1 Year $ ________________ $ _________________

2 Years $ ________________ $ _________________

3 Years $ ________________ $ _________________

4 Years $ ________________ $ _________________

5 Years $ ________________ $ _________________

End of the Total Amount

Year You Accumulation After Fees

Reach Age of IRA Dollars and Penalties

60 $ ________________ $ _________________

65 $ ________________ $ _________________

70 $ ________________ $ _________________

ADDITIONAL FINANCIAL DISCLOSURE INFORMATION

The account values shown are projections based on many assumptions.

These projections have been reduced by any applicable fees. They are not

guaranteed, but depend upon many factors, including the interest rates

and terms of future funding instruments.

We may charge you an annual service fee or other fees in connection with

your IRA. If we do not charge these fees now, we may do so in the future

after giving you notice. If you do not pay these fees separately, they may

be paid from the assets of your IRA.

CURRENT FEES

___________________________________ $ _____________________

*Conversion applies to Roth IRAs only

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IRA Simplifier ROTH INDIVIDUAL RETIREMENT ACCOUNT APPLICATION (Georgia's Own Credit Union)

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