Fill - Free fillable Roth Individual Retirement Trust Account Form-5305-R PDF form

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

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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