Form 5305-R
(Rev. April 2017)
Department of the Treasury
Internal Revenue Service
Roth Individual Retirement Trust Account
(Under section 408A of the Internal Revenue Code)
Do not file
with the Internal
Revenue Service
Name of grantor Date of birth of grantor
Account number
Address of grantor
Check if amendment . . .
Name of trustee Address or principal place of business of trustee
The grantor named above is establishing a Roth individual retirement account (Roth IRA) under section 408A to provide for his or
her retirement and for the support of his or her beneficiaries after death.
The trustee named above has given the grantor the disclosure statement required by Regulations section 1.408-6.
The grantor has assigned the trust .
$
The grantor and the trustee make the following agreement.
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 trustee 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 a grantor 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 grantor filing jointly, between AGI of $186,000 and $196,000; and for a married grantor 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 grantor and his or her
spouse.
Article III
The grantor’s interest in the balance in the trust account is nonforfeitable.
Article IV
1. No part of the trust account funds may be invested in life insurance contracts, nor may the assets of the trust account be
commingled with other property except in a common trust fund or common investment fund (within the meaning of section 408(a)(5)).
2. No part of the trust account funds may be invested in collectibles (within the meaning of section 408(m)) except as otherwise
permitted by section 408(m)(3), which provides an exception for certain gold, silver, and platinum coins, coins issued under the laws
of any state, and certain bullion.
Article V
1. If the grantor dies before his or her entire interest is distributed to him or her and the grantor’s surviving spouse is not the
designated beneficiary, the remaining interest 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 will be distributed, starting by the end of the calendar year following the year of the grantor’s death, over
the designated beneficiary’s remaining life expectancy as determined in the year following the death of the grantor.
(b) The remaining interest will be distributed by the end of the calendar year containing the fifth anniversary of the grantor’s death.
2. The minimum amount that must be distributed each year under paragraph 1(a) above is the account value at the close of
business on December 31 of the preceding year divided by the life expectancy (in the single life table in Regulations section
1.401(a)(9)-9) of the designated beneficiary using the attained age of the beneficiary in the year following the year of the grantor’s
death and subtracting 1 from the divisor for each subsequent year.
3. If the grantor’s surviving spouse is the designated beneficiary, such spouse will then be treated as the grantor.
Article VI
1. The grantor agrees to provide the trustee 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 trustee agrees to submit to the IRS and grantor the reports prescribed by the IRS.
Cat. No. 25093N
Form 5305-R (Rev. 4-2017)
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Form 5305-R (Rev. 4-2017)
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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, and other published guidance will be
invalid.
Article VIII
This agreement 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 below.
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.
Grantor’s signature Date
Trustee’s signature Date
Witness’ signature Date
(Use only if signature of the grantor or the trustee is required to be witnessed.)
General Instructions
Section references are to the Internal
Revenue Code unless otherwise noted.
Purpose of Form
Form 5305-R is a model trust account
agreement that meets the requirements
of section 408A. However, only Articles I
through VIII have been reviewed by the
IRS. A Roth individual retirement
account (Roth IRA) is established after
the form is fully executed by both the
individual (grantor) and the trustee. This
account must be created in the United
States for the exclusive benefit of the
grantor and his or her beneficiaries.
Do not file Form 5305-R 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 grantor’s gross
income; and distributions after 5 years
that are made when the grantor 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 trustee must give the grantor, see
Pub. 590-A, Contributions to Individual
Retirement Arrangements (IRAs), and
Pub. 590-B, Distributions from Individual
Retirement Arrangements (IRAs).
Definitions
Trustee. The trustee must be a bank or
savings and loan association, as defined
in section 408(n), or any person who has
the approval of the IRS to act as trustee.
Grantor. The grantor is the person who
establishes the trust account.
Specific Instructions
Article I. The grantor may be subject to
a 6% tax on excess contributions if
(1) contributions to other individual
retirement arrangements of the grantor
have been made for the same tax year,
(2) the grantor’s adjusted gross income
exceeds the applicable limits in Article II
for the tax year, or (3) the grantor’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 grantor’s death. Elections
made pursuant to this article should be
reviewed periodically to ensure they
correspond to the grantor’s intent. Under
paragraph 3 of Article V, the grantor’s
spouse is treated as the owner of the
Roth IRA upon the death of the grantor,
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 grantor and
trustee to complete the agreement. They
may include, for example, definitions,
investment powers, voting rights,
exculpatory provisions, amendment and
termination, removal of the trustee,
trustee’s fees, state law requirements,
beginning date of distributions,
accepting only cash, treatment of
excess contributions, prohibited
transactions with the grantor, etc. Attach
additional pages if necessary.
Form 5305-R (Rev. 4-2017)
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