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6314 / 2406R (Rev. 4/2015) ©2015 Ascensus, Inc.
PART 7. WITHDRAWAL INSTRUCTIONS
ASSET HANDLING (Assets idened below will be liquidated immediately unless otherwise specied in the Special Instrucons secon.)
Asset Descripon Amount to be Withdrawn Special Instrucons
__________________________________________ ______________________ __________________________________________________________________
__________________________________________ ______________________ __________________________________________________________________
__________________________________________ ______________________ __________________________________________________________________
PAYMENT METHOD
Cash
Check (If the withdrawal reason is transfer to another Roth IRA, the check must be made payable to the receiving organizaon.)
Make payable to __________________________________________________________________________________________________________
Internal Account
Account Number _____________________________________________ Type (e.g., checking, savings, Roth IRA) ____________________________
External Account (e.g., EFT, ACH, wire) (Addional documentaon may be required and fees may apply.)
Name of Organizaon Receiving the Assets ___________________________________________ Roung Number (Oponal) _________________
Account Number _____________________________________________ Type (e.g., checking, savings, Roth IRA) ____________________________
PART 8. SIGNATURES
I cerfy that I am authorized to receive payments from this Roth IRA and that all informaon provided by me is true and accurate. I have received a
copy of the Withholding Noce Informaon. 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 authorizaon.
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 Informaon About Withholding From Pensions and Annuies. Generally, federal income tax withholding applies to the taxable part of payments made from
pension, prot sharing, stock bonus, annuity, and certain deferred compensaon plans; from IRAs; and from commercial annuies.
Cauon: There may be penales for not paying enough tax during the year, through either withholding or esmated tax payments. New rerees should see Publicaon
505, Tax Withholding and Esmated Tax. It explains the esmated tax requirements and penales in detail. You may be able to avoid quarterly esmated 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 rerement accounts (IRAs). You can
use Form W-4P (or a substute 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 substute 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 elecon will remain in eect for any subsequent withdrawal unless you change or revoke it.
Payments Delivered Outside of the U.S. A U.S. cizen 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, Cercate of Foreign Status of Benecial Owner
for United States Tax Withholding, or sases the documentaon requirements as provided under federal regulaons. The Form W-8BEN must contain the foreign
person’s taxpayer idencaon number.
For more informaon, Publicaon 515, Withholding of Tax on Nonresident Aliens and Foreign Enes, and Publicaon 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 Exempon From Withholding. If you want to revoke your previously led exempon 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 distribuons 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 Roth IRA Owner ______________________________________________________________, Account Number ________________________
