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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

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1. Account Information

Your Name:

Email:

American IRA Account Number:

2. Wiring Instructions

Bank Name

Bank Routing Number

Bank Address

City

State

Bank Account Name

Bank Account Number

Address of Bank Account

Further Credit To

City

State

3. ACH

Bank Routing Number

LIMIT OF $5,000

Account Name :

Account Number

4. Signature and Acknowledgement

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).

Print Name:

Your Signature:

Date:

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

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Contact Information