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6314 / 2406R (Rev. 3/2019) ©2019 Ascensus, LLC
Name of Roth IRA Owner , Account Number
PART 7. WITHDRAWAL INSTRUCTIONS
ASSET HANDLING (Assets identified below will be liquidated immediately unless otherwise specified in the Special Instructions section.)
Asset Description Amount to be Withdrawn Special Instructions
PAYMENT METHOD
Cash
Check (If the withdrawal reason is transfer to another Roth IRA, the check must be made payable to the receiving organization.)
Make payable to
Internal Account
Account Number Type (e.g., checking, savings, Roth IRA)
External Account (e.g., EFT, ACH, wire) (Additional documentation may be required and fees may apply.)
Name of Organization Receiving the Assets Routing Number (Optional)
Account Number Type (e.g., checking, savings, Roth IRA)
PART 8. SIGNATURES
I certify that I am authorized to receive payments from this Roth IRA and that all information provided by me is true and accurate. I have received a
copy of the Withholding Notice Information. 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 authorization.
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 Information About Withholding From Pensions and Annuities. Generally, federal income tax withholding applies to the taxable part of payments made from
pension, profit sharing, stock bonus, annuity, and certain deferred compensation plans; from IRAs; and from commercial annuities.
Caution: There may be penalties for not paying enough tax during the year, through either withholding or estimated tax payments. New retirees should see Publication
505, Tax Withholding and Estimated Tax. It explains the estimated tax requirements and penalties in detail. You may be able to avoid quarterly estimated 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 retirement accounts (IRAs). You can
use Form W-4P (or a substitute 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 substitute 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 election will remain in effect for any subsequent withdrawal unless you change or revoke it.
Payments Delivered Outside of the U.S. A U.S. citizen 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, Certificate of Foreign Status of Beneficial Owner
for United States Tax Withholding, or satisfies the documentation requirements as provided under federal regulations. The Form W-8BEN must contain the foreign
person’s taxpayer identification number.
For more information, Publication 515, Withholding of Tax on Nonresident Aliens and Foreign Entities, and Publication 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 Exemption From Withholding. If you want to revoke your previously filed exemption from withholding, file 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 distributions 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.
ELECTRONIC TRANSFER NOT AVAILABLE
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