Form 5305-RB
(Rev. April 2017)
Department of the Treasury
Internal Revenue Service
Roth Individual Retirement Annuity Endorsement
(Under section 408A of the Internal Revenue Code)
Do not file
with the Internal
Revenue Service
Name of issuer
Check if this endorsement supersedes a prior Roth IRA
endorsement . . . . . . . . . . . .
This endorsement is made a part of the annuity contract to which it is attached, and the following provisions apply in lieu of any
provisions in the contract to the contrary.
The annuitant is establishing a Roth individual retirement annuity (Roth IRA) under section 408A to provide for his or her retirement
and for the support of his or her beneficiaries after death.
Article I
Except in the case of a qualified rollover contribution described in section 408A(e) or a recharacterized contribution described in
section 408A(d)(6), the issuer will accept only cash contributions up to $5,500 per year for 2013 through 2017. For individuals who
have reached the age of 50 by the end of the year, the contribution limit is increased to $6,500 per year for 2013 through 2017. For
years after 2017, these 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 an annuitant who is
single or treated as single, the annual contribution is phased out between adjusted gross income (AGI) of $118,000 and $133,000; for
a married annuitant filing jointly, between AGI of $186,000 and $196,000; and for a married annuitant filing separately, between AGI of
$0 and $10,000. These phase-out ranges are for 2017. For years after 2017, the phase-out ranges, except for the $0 to $10,000 range,
will be increased to reflect a cost-of-living adjustment, if any. Adjusted gross income is defined in section 408A(c)(3).
2. In the case of a joint return, the AGI limits in the preceding paragraph apply to the combined AGI of the annuitant and his or her
spouse.
Article III
The annuitant’s interest in the contract is nonforfeitable and nontransferable.
Article IV
1. The contract does not require fixed contributions.
2. Any dividends (refund of contributions other than those attributable to excess contributions) arising under the contract will be
applied (before the close of the calendar year following the year of the dividend) as contributions toward the contract.
Article V
1. If the annuitant dies before his or her entire interest in the contract is distributed to him or her and the annuitant’s surviving
spouse is not the designated beneficiary, the remaining interest in the contract will be distributed in accordance with paragraph (a)
below or, if elected or there is no designated beneficiary, in accordance with paragraph (b) below.
(a) The remaining interest in the contract will be distributed, starting by the end of the calendar year following the year of the
annuitant’s death, over the designated beneficiary’s remaining life expectancy, or a period no longer than such remaining life
expectancy, as determined in the year following the death of the annuitant. Life expectancy is determined using the single life table in
Regulations section 1.401(a)(9)-9.
(b) The remaining interest in the contract will be distributed by the end of the calendar year containing the fifth anniversary of the
annuitant’s death.
2. If the annuitant’s surviving spouse is the designated beneficiary, such spouse will then be treated as the annuitant.
Article VI
1. The annuitant agrees to provide the issuer 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 issuer agrees to submit to the IRS and annuitant 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, or other published guidance will be
invalid.
Cat. No. 25871H
Form 5305-RB (Rev. 4-2017)
Form 5305-RB (Rev. 4-2017)
Page 2
Article VIII
This endorsement 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 contract.
Article IX
Article IX may be used for any additional provisions. If no other provisions will be added, draw a line through this space. If
provisions are added, they must comply with applicable requirements of state law and the Internal Revenue Code and may not imply
that they have been reviewed or pre-approved by the IRS.
General Instructions
Section references are to the Internal
Revenue Code unless otherwise noted.
Purpose of Form
Form 5305-RB is a model annuity
endorsement that meets the
requirements of section 408A. However,
only Articles I through VIII have been
reviewed by the IRS. A Roth individual
retirement annuity (Roth IRA) is
established after the contract, which
includes this endorsement, is fully
executed by both the individual
(annuitant) and the issuer. To make a
regular contribution to a Roth IRA for a
year, the IRA must be established no
later than the due date (excluding
extensions) of the individual’s income tax
return for the year. The contract must be
for the exclusive benefit of the annuitant
and his or her beneficiaries.
Do not file Form 5305-RB 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 annuitant’s gross
income; and distributions after 5 years
that are made when the annuitant is
59
1
/2 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 issuer must give
the annuitant, see Pub. 590-A,
Contributions to Individual Retirement
Arrangements (IRAs), and Pub. 590-B,
Distributions from Individual Retirement
Arrangements (IRAs).
Definitions
Issuer. The issuer is the insurance
company providing the annuity contract.
The insurance company may use other
terms besides “issuer” to refer to itself,
such as, “company,” “insurer,” or “us.”
Annuitant. The annuitant is the person
who establishes the annuity contract.
The insurance company may use other
terms besides “annuitant” to refer to the
person who establishes the annuity
contract, such as, “owner,” “applicant,”
“insured,” or “you.”
Specific Instructions
Article I. The annuitant may be subject
to a 6% tax on excess contributions if
(1) contributions to other individual
retirement arrangements of the annuitant
have been made for the same tax year,
(2) the annuitant’s adjusted gross
income exceeds the applicable limits in
Article II for the tax year, or (3) the
annuitant’s and spouse’s compensation
is less than the amount contributed by
or on behalf of them for the tax year.
Article V. This article describes how
distributions will be made from the Roth
IRA after the annuitant’s death. Elections
made pursuant to this article should be
reviewed periodically to ensure they
correspond to the annuitant’s intent.
Under paragraph 2 of Article V, the
annuitant’s spouse is treated as the
owner of the Roth IRA upon the death of
the annuitant, 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 annuitant and
issuer to complete the contract. They
may include, for example, definitions,
investment powers, voting rights,
exculpatory provisions, amendment and
termination, removal of the issuer,
issuer’s fees, state law requirements,
beginning date of distributions,
accepting only cash, treatment of
excess contributions, prohibited
transactions with the annuitant, etc.
Attach additional pages if necessary.
Form 5305-RB (Rev. 4-2017)
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