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Payment Authorization Form

1. Account Information

Your Name:

Account Number:

How would you like this transaction processed?

Email:

2. Asset Description

IRN/Asset Description/Property Address:

Percentage of Ownership:

3. Payment Description

Amount to be Paid:

Frequency of Payment:

Type of Expense:

Other Description:

Start Date:

Ending Date:

Account No./Billing No./Invoice No./ETC.

Any information that will assist with identifying your payment.

4. Funding

Funding Instructions Please send the funds via:

For WIRE ($30 Fees)

For ACH ($10 Fees)

I am attaching Wire Instructions

Attach Document

Bank Name:

ABA Routing Number:

Bank City:

Bank State:

Account Holder Name:

Account Number:

Account Holder Address:

Street Address:

City:

State:

Zip:

Make Check Payable To:

Mail Check to:

(if different from whom the check is made payable)

Mailing Address:

Street Address:

City:

State:

Zip:

Send Check Via:

If payment is over $5,000 it will be mailed certified mail unless marked otherwise below.

Upload your Invoice HERE

Invoices, Taxes, Mortgage Statement, ETC.

Corporate Headquarters: New Vision Trust Company, 401 E. 8th Street, Suite 200R, Sioux Falls, South Dakota 57103

5. Signatures and Acknowledgement:

My account is self-directed and I, alone, am responsible for the selection, due diligence, management, review, and retention of all investments in my account. I agree that the Custodian and Administrator are not a fiduciary for my account, as the term is defined in the IRC, ERISA, or any other applicable federal, state, or local laws and this payment does not constitute a prohibited transaction as defined in IRC 4975. I acknowledge and confirm that I have received, read and understand each of the disclosures for my account(s) and direction(s) of investment, and consent and agree to the terms and conditions contained therein. I direct American IRA, LLC to execute the payment of the above-referenced expenses for the benefit of my account. I agree to hold American IRA, LLC harmless from any liability for any loss, damage, injury or expense which may occur as a result of the execution of this payment authorization form, a facsimile, electronic or other form of this request may be submitted if acceptable to the custodian. I understand that American IRA, LLC will have a reasonable amount of time to complete my instructions. I understand that if my request would cause my account to drop below the required minimum account cash balance, the request will not be processed. American Ira, LLC may contact me for verbal confirmation of my expense payment instructions, which may cause delays if I cannot be reached at the phone number listed on file.
By my signature below, I confirm that I have read and consent to the terms of this document and I further acknowledge that I have read and consent to the terms of the New Account Application, Custodial Agreement (Form 5305, 5305-A, 5305-RA, 5305-SA, 5305-SEP, 5305-C or 5305-EA, as application, “collectively referred to as “5305” or 401K Plan Agreement (“Sponsored Plan”) as applicable, Fee Schedule, Account Disclosure Statement and any other documents that govern my Custodial Account or Sponsored Plan, as such documents are currently written, or as they may be amended from time to time, (the “Documents”), which are incorporated by reference herein. (In the event of a conflict between the Documents and the 5305 and/or Sponsored Plan applicable to my Custodial Account, the 5305 or Sponsored Plan shall govern).

I Accept the Acknowledgement

Signature:

Date:

Please note we will retain enough cash in your Custodial Account to maintain your minimum required balance, and to cover any investment-related fees or any unpaid fees before sending your requested amount. If there are insufficient funds to cover the minimum balance and/or fees, your request will be put on hold until sufficient funds are available.

Corporate Headquarters: New Vision Trust Company, 401 E. 8th Street, Suite 200R, Sioux Falls, South Dakota 57103

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