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6314 / 2406R (Rev. 3/2019) ©2019 Ascensus, LLC
Roth IRA
ROTH
IRA
WITHDRAWAL AUTHORIZATION
Refer to pages 2 and 3 of this form for reporting and withholding notice information.
PART 1. ROTH IRA OWNER
Name (First/MI/Last)
Social Security Number
Date of Birth Phone
Email Address
Account Number Suffix
PART 2. ROTH IRA TRUSTEE OR CUSTODIAN
To be completed by the Roth IRA trustee or custodian
Name
Address Line 1
Address Line 2
City/State/ZIP
Phone Organization Number
PART 3. BENEFICIARY OR FORMER SPOUSE INFORMATION
This section should only be completed by a beneficiary 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 settlement due to divorce or legal separation.
Name (First/MI/Last)
Tax ID (SSN/TIN)
Date of Birth Phone
Account Number Suffix
Address Line 1
Address Line 2
City/State/ZIP
PART 4. WITHDRAWAL INFORMATION
Total Withdrawal Amount
Withdrawal Date
This Withdrawal Will Close This Roth IRA
The five-year period for qualified withdrawals has been satisfied.
WITHDRAWAL REASON (Select one)
1. Transfer to Another Roth IRA
2. Age 59½ or Older
3. Under Age 59½ (Select a or b if applicable)
a. Disability
b. IRS Levy or Substantially Equal Periodic Payments
4. Death Withdrawal by a Beneficiary
5. Prohibited Transaction
6. Excess Contribution Removed Before the Excess Removal Deadline
(Enter the net income attributable to the excess and select a or b)
Net Income Attributable
a. Excess Contributed and Removed in the Same Year
b.
Excess Contributed in One Year and Removed in the Next Year
7. Excess Contribution Removed After the Excess Removal Deadline
8. Recharacterization (Enter the net income attributable to the
recharacterized amount and select a or b)
Net Income Attributable
a. Same-Year Recharacterization
b. Prior-Year Recharacterization
9. Revocation (Enter the earnings amount and select a or b)
Earnings
a. Regular Contribution
b. Conversion Contribution
10. Revocation of Rollover or Transfer Contribution
PART 5.
WITHHOLDING ELECTION
(Form W-4P/OMB No. 1545-0074)
Do not complete this section for a transfer, recharacterization, or if you
are a nonresident alien.
Your withholding election will remain in effect for any subsequent
withdrawal unless you change or revoke it.
FEDERAL WITHHOLDING (Select one)
Withhold % (Must be 10% or greater)
Withhold Additional 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 section may be completed for informational purposes only.
Trustee or Custodian Penalties and Fees
Gross Withdrawal Amount*
Federal Withholding Amount
State Withholding Amount
Net Amount Paid to Recipient
* The gross withdrawal amount is the total withdrawal amount in Part 4
after any penalties and fees assessed by the trustee or custodian.
KINECTA FEDERAL CREDIT UNION
1440 ROSECRANS AVE
MANHATTAN BEACH CA 90266
(800) 854-9846
11379
CALIFORNIA Residents Only
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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
XXXXXN/AXXXX
XXXXXXXXXXXXXN/AXXXXXXXXXXXXX
XXXXXXXXN/AXXXXXXX
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6314 / 2406R (Rev. 3/2019) ©2019 Ascensus, LLC
REPORTING INFORMATION APPLICABLE TO ROTH IRA WITHDRAWALS
You must supply all requested information for the withdrawal so the trustee or custodian can properly report the withdrawal.
If you have any questions regarding a withdrawal, please consult a competent tax professional or refer to IRS Publication 590-B, Distributions from
Individual Retirement Arrangements (IRAs), for more information. This publication is available on the IRS website at www.irs.gov or by calling
1-800-TAX-FORM.
WITHDRAWAL INFORMATION
Roth IRA assets can be withdrawn at any time. Most Roth IRA withdrawals are reported to the IRS. IRS rules specify the distribution code that must be
used to report each withdrawal on IRS Form 1099-R, Distributions From Pensions, Annuities, Retirement or Profit-Sharing Plans, IRAs, Insurance
Contracts, etc.
Five-Year Period. You have satisfied the five-year period for determining qualified withdrawals on January 1 of the fifth year following the year for
which you made your first Roth IRA contribution, conversion, or rollover from an eligible employer-sponsored retirement plan.
Qualified Withdrawal. A qualified withdrawal is one where you have satisfied the five-year waiting period and the withdrawal is due to being age
59½ or older, death, or disability. Qualified withdrawals are reported on Form 1099-R using code Q.
WITHDRAWAL REASON
Transfer to Another Roth IRA. Transfers are not reported on Form 1099-R. Transfers may be made by a Roth IRA owner, beneficiary, 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 beneficiary.
Age 59½ or Older. If you are age 59½ or older, withdrawals are reported on Form 1099-R using code T, unless they are qualified withdrawals.
Under Age 59½. If you are under age 59½, withdrawals for any reason not listed below are reported on Form 1099-R using code J.
Disability. If you are under age 59½ and disabled, withdrawals are reported on Form 1099-R using code T, unless they are qualified withdrawals.
IRS Levy or Substantially Equal Periodic Payments. If you are under age 59½, withdrawals due to IRS levy or substantially equal periodic
payments are reported on Form 1099-R using code 2. Certain distributions taken due to federally declared disasters also are reported using
code 2. Please refer to the IRS website at www.irs.gov for more information and a listing of the disaster areas.
Death Withdrawal by a Beneficiary. Withdrawals by beneficiaries following the death of the original Roth IRA owner are reported on Form 1099-R
using code T, unless they are qualified withdrawals.
Prohibited Transaction. Prohibited transactions as defined in Internal Revenue Code Section 4975(c) are reported on Form 1099-R using code 5.
Excess Contribution Removed Before the Excess Removal Deadline. Excess contributions removed before the excess removal deadline (your tax filing
deadline, including extensions) must include the net income attributable to the excess.
If your excess contribution was contributed and removed in the same year, before the excess removal deadline, the withdrawal is reported on
Form 1099-R using codes 8 and J.
If your excess contribution 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 codes P and J.
Excess Contribution Removed After the Excess Removal Deadline. If your excess contribution is removed after the excess removal deadline, the
withdrawal is reported on Form 1099-R using code J if you are under age 59½, code T if you are age 59½ or older, or code Q if the distribution is a
qualified withdrawal.
Recharacterization. A Roth IRA contribution including the net income attributable may be recharacterized as a Traditional IRA contribution up until
your tax filing deadline, including extensions.
Recharacterizations that occur in the same year for which the contribution was made are reported on Form 1099-R using code N.
Recharacterizations that occur after the year for which the contribution was made are reported on Form 1099-R using code R.
Revocations. Revocations of regular contributions, conversions, rollovers, or transfers are reported on Form 1099-R using code J. A revocation of a
regular contribution with earnings if you are under age 59½ is reported on Form 1099-R using codes J and 8.