Fill - Free fillable IRA WITHDRAWAL AUTHORIZATION (Georgia's Own Credit Union) PDF form

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WITHDRAWAL AUTHORIZATION

The term IRA will be used below to mean Tradional IRA and SIMPLE IRA, unless otherwise specied.

Refer to pages 2 and 3 of this form for reporng and withholding noce informaon.

PART 1. IRA OWNER

Name (First/MI/Last) _________________________________________

Social Security Number _______________________________________

Date of Birth ____________________ Phone _____________________

Email Address _______________________________________________

Account Number__________________________________ Sux _____

ACCOUNT TYPE (Select one)

Tradional IRA SIMPLE IRA

PART 2. IRA TRUSTEE OR CUSTODIAN

To be completed by the IRA trustee or custodian

Name _____________________________________________________

Address Line 1 ______________________________________________

Address Line 2 ______________________________________________

City/State/ZIP _______________________________________________

Phone________________________ Organizaon Number ___________

PART 4. WITHDRAWAL INFORMATION

Total Withdrawal Amount _____________________________________

Withdrawal Date _____________________________________________

This Withdrawal Will Close This IRA

WITHDRAWAL REASON (Select one)

1. Transfer to Another IRA

2. Normal Withdrawal (Age 59

⁄2 or older)

3. Early Withdrawal (Under age 59

⁄2) (Select a, b, or c if applicable)

a. Disability

b. Direct Conversion to a Roth IRA, Substanally Equal

Periodic Payments, or IRS Levy

c. SIMPLE IRA Withdrawal in the First Two Years (No IRS

penalty excepon)

4. Death Withdrawal by a Beneciary

5. Direct Rollover to an Eligible Employer-Sponsored Rerement Plan

6. Prohibited Transacon

7. Excess Contribuon Removed Before the Excess Removal Deadline

(Enter the net income aributable to the excess and select a or b)

Net Income Aributable _________________________________

a. Excess Contributed and Removed in the Same Year

Excess Contributed in One Year and Removed in the Next Year

8. Excess Contribuon Removed Aer the Excess Removal Deadline

9. SEP or SIMPLE IRA Excess Contribuon Removed Under the EPCRS

10. Recharacterizaon (Enter the net income aributable to the

recharacterized amount and select a or b)

Net Income Aributable _________________________________

a. Same-Year Recharacterizaon

b. Prior-Year Recharacterizaon

11. Revocaon of a Regular Contribuon

Earnings ______________________________________________

12. Revocaon of a Rollover, Transfer, or SEP Contribuon

PART 3. BENEFICIARY OR FORMER SPOUSE INFORMATION

This secon should only be completed by a beneciary taking a death withdrawal or transferring inherited IRA assets to another IRA, or by a former

spouse taking a withdrawal as a result of a court-approved property selement due to divorce or legal separaon.

Name (First/MI/Last) __________________________________________ Address Line 1 _______________________________________________

Tax ID (SSN/TIN) ______________________________________________ Address Line 2 _______________________________________________

Date of Birth ____________________ Phone ______________________ City/State/ZIP ________________________________________________

PART 5.

WITHHOLDING ELECTION

(Form W-4P/OMB No. 1545-0074)

Do not complete this secon for a transfer, recharacterizaon, or direct

rollover to an eligible employer-sponsored rerement plan, or if you are a

nonresident alien.

Your withholding elecon will remain in eect for any subsequent

withdrawal unless you change or revoke the elecon.

FEDERAL WITHHOLDING (Select one)

Withhold ________ % (Must be 10% or greater)

Withhold Addional Federal Income Tax of $ ___________________

(If applicable)

Do Not Withhold Federal Income Tax

STATE WITHHOLDING (If applicable, select one)

Name of Withholding State ____________________________________

Withhold ________ %

Withhold $___________________

Do Not Withhold State Income Tax

PART 6. WITHDRAWAL SUMMARY

This secon may be completed for informaonal purposes only.

Trustee or Custodian Penales and Fees _________________________

Gross Withdrawal Amount _________________________

Federal Withholding Amount _________________________

State Withholding Amount _________________________

Net Withdrawal Amount _________________________

Note: The gross withdrawal amount is the amount aer any penales

and fees assessed by the trustee or custodian.

TRADITIONAL

& SIMPLE

IRA

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PART 7. WITHDRAWAL INSTRUCTIONS

ASSET HANDLING (Assets idened below will be liquidated immediately unless otherwise specied in the Special Instrucons secon.)

Asset Descripon Amount to be Withdrawn Special Instrucons

__________________________________________ ______________________ __________________________________________________________________

PAYMENT METHOD

Cash

Check (If the withdrawal reason is transfer to another IRA, direct conversion to a Roth IRA, or direct rollover to an eligible employer-sponsored

rerement plan, the check must be made payable to the receiving organizaon.)

Make payable to __________________________________________________________________________________________________________

Internal Account

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

External Account (e.g., EFT, ACH, wire) (Addional documentaon may be required and fees may apply.)

Name of Organizaon Receiving the Assets ___________________________________________ Roung Number (Oponal) _________________

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

PART 8. SIGNATURES

I cerfy that I am authorized to receive payments from this IRA and that all informaon provided by me is true and accurate. I have received a copy

of the Withholding Noce Informaon. No tax advice has been given to me by the trustee or custodian. All decisions regarding this withdrawal are

my own, and I expressly assume responsibility for any consequences that may arise from this withdrawal. I agree that the trustee or custodian is not

responsible for any consequences that may arise from processing this withdrawal authorizaon.

X_________________________________________________________________________________________________ ______________________________________

Signature of Recipient Date (mm/dd/yyyy)

X_________________________________________________________________________________________________ ______________________________________

Notary Public/Signature Guarantee (If required by the trustee or custodian) Date (mm/dd/yyyy)

X_________________________________________________________________________________________________ ______________________________________

Authorized Signature of Trustee or Custodian Date (mm/dd/yyyy)

WITHHOLDING NOTICE INFORMATION (Form W-4P/OMB No. 1545-0074)

Basic Informaon About Withholding From Pensions and Annuies. Generally, federal income tax withholding applies to the taxable part of payments made from

pension, prot sharing, stock bonus, annuity, and certain deferred compensaon plans; from IRAs; and from commercial annuies.

Cauon: There may be penales for not paying enough tax during the year, through either withholding or esmated tax payments. New rerees should see Publicaon

505, Tax Withholding and Esmated Tax. It explains the esmated tax requirements and penales in detail. You may be able to avoid quarterly esmated tax payments

by having enough tax withheld from your IRA using form W-4P.

Purpose of Form W-4P. Unless you elect otherwise, 10 percent federal income tax will be withheld from payments from individual rerement accounts (IRAs). You can

use Form W-4P (or a substute form, such as this form), provided by the trustee or custodian, to instruct your trustee or custodian to withhold no tax from your IRA

payments or to withhold more than 10 percent. This substute form should be used only for withdrawals from IRAs that are payable upon demand.

Nonperiodic Payments. Payments made from IRAs that are payable upon demand are treated as nonperiodic payments for federal income tax purposes. Generally,

nonperiodic payments must have at least 10 percent income tax withheld.

Your elecon will remain in eect for any subsequent withdrawal unless you change or revoke it.

Payments Delivered Outside of the U.S. A U.S. cizen or resident alien may not waive withholding on any withdrawal delivered outside of the U.S. or its possessions.

Withdrawals by a nonresident alien generally are subject to a tax withholding rate of 30 percent. A reduced withholding rate may apply if there is a tax treaty between

the nonresident alien’s country of residence and the United States and if the nonresident alien submits Form W-8BEN, Cercate of Foreign Status of Benecial Owner

for United States Tax Withholding, or sases the documentaon requirements as provided under federal regulaons. The Form W-8BEN must contain the foreign

person’s taxpayer idencaon number.

For more informaon, Publicaon 515, Withholding of Tax on Nonresident Aliens and Foreign Enes, and Publicaon 519, U.S. Tax Guide for Aliens, are available on the

IRS website at www.irs.gov or by calling 1-800-TAX-FORM.

Revoking the Exempon From Withholding. If you want to revoke your previously led exempon from withholding, le another Form W-4P with the trustee or

custodian and check the appropriate box on that form.

Statement of Income Tax Withheld From Your IRA. By January 31 of next year, your trustee or custodian will provide a statement to you and to the IRS showing the

total amount of your IRA distribuons and the total federal income tax withheld during the year. Copies of Form W-4P will not be sent to the IRS by the trustee or

custodian.

Name of IRA Owner ______________________________________________________________, Account Number _____________________________

Page 3 of 3

REPORTING INFORMATION APPLICABLE TO TRADITIONAL IRA AND SIMPLE IRA WITHDRAWALS

You must supply all requested informaon for the withdrawal so the trustee or custodian can properly report the withdrawal.

If you have any quesons regarding a withdrawal, please consult a competent tax professional or refer to IRS Publicaon 590-B, Distribuons from

Individual Rerement Arrangements (IRAs), for more informaon. This publicaon is available on the IRS website at www.irs.gov or by calling

1-800-TAX-FORM.

WITHDRAWAL REASON

IRA assets can be withdrawn at any me. Most IRA withdrawals are reported to the IRS. IRS rules specify the distribuon code that must be used to

report each withdrawal on IRS Form 1099-R, Distribuons From Pensions, Annuies, Rerement or Prot-Sharing Plans, IRAs, Insurance Contracts, etc.

Transfer to Another IRA. Transfers are not reported on Form 1099-R. Transfers may be made by an IRA owner, beneciary, or former spouse under a

transfer due to a divorce. Inherited IRA assets may only be transferred to another inherited IRA, unless you are a spouse beneciary.

Normal Withdrawal (Age 59

⁄2 or older). If you are age 59

⁄2 or older, withdrawals (including required minimum distribuons) are reported on Form

1099-R using code 7.

Early Withdrawal (Under age 59

⁄2). If you are under age 59

⁄2, withdrawals for any reason not listed below are reported on Form 1099-R using code 1.

• Disability. If you are under age 59

⁄2 and disabled, withdrawals are reported on Form 1099-R using code 3.

• Direct Conversion to a Roth IRA, Substanally Equal Periodic Payments, or IRS Levy. If you are under age 59

⁄2, withdrawals due to direct

conversions to a Roth IRA, substanally equal periodic payments, or IRS levy are reported on Form 1099-R using code 2.

• SIMPLE IRA Withdrawal in the First Two Years (No IRS penalty excepon). If you are under age 59

⁄2 and less than two years have passed since

the rst contribuon to your SIMPLE IRA, withdrawals are reported on Form 1099-R using code S.

Death Withdrawal by a Beneciary. Withdrawals by beneciaries following the death of the original IRA owner are reported on Form 1099-R using

code 4. Use code G with code 4 for a surviving spouse beneciary who elects a direct rollover to an eligible employer-sponsored rerement plan.

Direct Rollover to an Eligible Employer-Sponsored Rerement Plan. Direct rollovers to eligible employer-sponsored rerement plans (Internal

Revenue Code Secon (IRC Sec.) 401(a) (e.g., 401(k), prot sharing, money purchase pension plan), annuity plan (IRC Sec. 403(a)), tax-sheltered

annuity plan (IRC Sec. 403(b)), or governmental deferred compensaon plan (IRC Sec. 457(b)) are reported on Form 1099-R using code G.

Prohibited Transacon. Prohibited transacons as dened in IRC Sec. 4975(c) are reported on Form 1099-R using code 5.

Excess Contribuon Removed Before the Excess Removal Deadline. Excess contribuons removed before the excess removal deadline (your tax

ling deadline, including extensions) must include the net income aributable to the excess.

• If your excess contribuon was contributed and removed in the same year, before the excess removal deadline, the withdrawal is reported on

Form 1099-R using code 8. If you are under age 59

⁄2 also use code 1.

• If your excess contribuon was contributed in one year and removed in the next year, before the excess removal deadline, the withdrawal is

reported on Form 1099-R using code P. If you are under age 59

⁄2 also use code 1.

Excess Contribuon Removed Aer the Excess Removal Deadline. If your excess contribuon is removed aer the excess removal deadline, the

withdrawal is reported on Form 1099-R using code 1 if you are under age 59

⁄2 or code 7 if you are age 59

⁄2 or older.

SEP or SIMPLE IRA Excess Contribuon Removed Under the EPCRS. Excess SEP or SIMPLE IRA contribuons removed under the Employee Plans

Compliance Resoluon System (EPCRS) generally are reported on Form 1099-R using code E.

Recharacterizaon. A Tradional IRA contribuon including the net income aributable may be recharacterized as a Roth IRA contribuon up unl

your tax ling deadline, including extensions.

• Recharacterizaons that occur in the same year for which the contribuon was made are reported on Form 1099-R using code N.

• Recharacterizaons that occur aer the year for which the contribuon was made are reported on Form 1099-R using code R.

Revocaon of a Regular Contribuon. Revocaons of regular contribuons are reported on Form 1099-R using code 8. If you are under age 59

⁄2 and

earnings on the contribuon are distributed, also use code 1.

Revocaon of Rollover, Transfer, or SEP Contribuon. Revocaons of rollovers, transfers, or SEP plan contribuons are reported on Form 1099-R

using code 1 if you are under age 59

⁄2 or code 7 if you are age 59

⁄2 or older.

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IRA WITHDRAWAL AUTHORIZATION (Georgia's Own Credit Union)

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