A disclaimer is generally any statement intended to specify or delimit the scope of rights and obligations that may be exercised and enforced by parties in a legally recognized relationship

Agree

Distribution Request Form

1. Account Information

Your Name

Account Number

Phone Number

Email Address

Birthdate:

Social Security Number

Type of Account

2. Distribution Type (Complete one of the following groups below)

This distribution is from an IRA:(Review Distribution Type Chart For Explanation)

Traditional, SIMPLE, SEP

Premature With Exceptio

ALL TYPES

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ROTH

See our website for a complete explanation of distribution types

This distribution is from a Special Purpose Plan:

HSA or Coverdell ESA

Describe:

Is this a distribution due to death?

Beneficiary Name

Beneficiary SSN

Beneficiary Date of Birth

(MM/DD/YYYY)

Beneficiary Phone Number

Beneficiary Home Address

Beneficiary City

Beneficiary State

Beneficiary Zip

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

3. Distribution Details

Manner of Distribution

All Cash and In-Kind Assets

Type

Amount

$

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*A current appraisal must be provided to distribute assets in-kind

Frequency of Distribution

Would you like to set up a scheduled recurring distribution?**

Recurring Period

Date Payments to commence:

RMD’s are not processed on a recurring basis.

**A recurring distribution will remain in effect until you provide a written request to cancel or change. Recurring distribution payments incur a $25 fee per distribution.

Withholding

Federal Tax

Amount:

Percentage

%

State Tax(ONLY AVAILABLE FOR NC)

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$

Note: We encourage you to consult your accountant or tax advisor regarding your IRA distributions. Even if you elect not to have federal income tax withheld, you are liable for payment of federal income tax on the taxable portion of your distribution. You may be subject to tax penalties under the estimated tax payment rules if your payments of estimated tax and withholding are not adequate. While we make every effort to obtain information about state tax withholding laws, we do not guarantee the accuracy or the timeliness of state tax withholding information we provide, because state tax laws are subject to constant change and interpretation. The information we provide is not intended to serve as tax or legal advice, and we strongly recommend that you contact your tax advisor regarding your tax withholding elections and to obtain the most current information about your state’s withholding laws.

IN OFFICE CALCULATION (do not complete) we will complete and return to you for signature

Total Distribution Amount

$

Federal Withholding

$

State Withholdings

$

Fees withheld

$

Total amount payable to Account Holder

$

Account Holder elected to not have Federal withholdings

Account Holder elected to not have State withholdings

Signature of Acceptance by Account Holder

Date

Custodian and/or Administrator have provided this withholding calculation as a courtesy and is based on information provided to us by you, as the Account Holder. You are solely responsible for the accuracy of the calculation. The Custodian and/or Administrator shall not be held liable for the accuracy of the calculation and you, as the Account Holder, shall release Custodian and Administrator for any fees, additional taxes due, costs, penalties, damages and/or losses arising from or related to the accuracy of the above withholding calculation

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

4. Funding Instructions

Send funds via

Bank Name

ABA Routing Number

Account Holder Name

Account Number

For Credit To

*ACH Limit $5,000

Make Check Payable To

Mail Check To

Address

City

State

Zip

Send Check Via

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

5. Signatures and Acknowledgement

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.

I hereby acknowledge and confirm that I shall provide the Custodian and/or the Administrator the necessary supporting documentation within sixty (60) days from the funding of this investment from my Custodial Account. Failure to provide supporting documents within the sixty (60) day period may result in a distribution from my account. Such a distribution may result in fees and penalties. I further acknowledge that I am solely responsible for the investment updates I am making. I hold harmless, protect and indemnify the Custodian and/or Administrator from and against any and all liabilities, losses, damages, expenses and charges that the Custodian and/or Administrator arising from and/or related to this investment. NEITHER NEW VISION TRUST COMPANY, a state-chartered South Dakota Trust Company (“Custodian”) nor AMERICAN IRA, LLC, a North Carolina limited liability company (“Administrator”) have provided any legal or financial advice related to this or any other transaction(s) of my Custodial Account. I further acknowledge that I am solely responsible for the success or failure of this investment. I hereby authorized the update of the asset(s) listed above for my Custodial Account.

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

Print Name

Signature:

Date:

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