IRA Distribution Form - BankDirect

1 IRA Distribution Formfor Traditional and SIMPLE IRAsWITHHOLDING ELECTIONIRA OWNER INFORMATIONSIGNATURESDISTRIBUTION REASONPAYMENT INSTRUCTIONSS ignature of Custodian/TrusteeDateI certify that I am the IRA owner, the beneficiary, or individual legally authorized to complete this form . I certify the accuracy of the informationset forth in this form , and I authorize this transaction. I understand the custodian/trustee may require the completion of additional documentsbefore processing any distributions. I understand that I am responsible for any consequences resulting from this Distribution including taxes andpenalties owed. I indemnify and hold the custodian/trustee harmless from any resulting liabilities.

2 I acknowledge that the custodian/trustee cannotprovide me with legal advice, and I agree to consult with a tax or legal professional for of IRA Owner/BeneficiaryDateAccount TypeAccount Number(1)(2)(3)I elect distributions to be paid in thefollowing manner (select one):Date of DistributionAmount Requested$Penalties Charged(-)Administrative Fees(-)$Federal Income Tax Withheld(-)State Income Tax Withheld(-)Local Tax Withheld(-)$Earnings paid to date not already reported to IRAA dministration Provider (optional). Includethis figure in the Amount Requested. $Does this Distribution close the IRA? YesNo(Complete for IRS Levy, Death, Transfer, Recharacterization, Direct Rollover, and QHSAFD transactions.)

3 (1)of $.(2)I authorize automatic distributions of$onamonthlyannualquarterlyotherbasis, starting periodic distributions until Inotify you in writing otherwise.(3)(including transfers)Correction of Excess Contribution for Tax of excess $.In same year as excess contributionEarnings attributable to excess $.In year after excess contribution, but by my tax-filing duedate, including extensionsEarnings attributable to excess $.After my tax-filing due date, including extensionsRecharacterization of:Prior tax year regular contribution in the current yearCurrent tax year regular contribution in the current yearSIMPLE IRA Distribution During Two-Year Period(if younger than age 59 )Premature, no known exceptionPremature, exception applies (includes IRS Levy)DisabilityDeathProhibited TransactionRevocationNormalTransferTo my IRATo spouse's IRA due to death (only if sole beneficiary)To former spouse's IRA due to divorce or legal separationDirect Rollover to an employer-sponsored Eligible Retirement PlanQualified Health Savings Account Funding Distribution (QHSAFD)

4 I electto have Federal income tax withheld from my IRA elect to have 10 percent Federal income tax withheld from my IRA want the followingdollar amount ($), orpercentage (%) withheld from each IRA elect to have $or% State income tax withheld from my IRA Distribution (if applicable).The instructions to form W-4P (Withholding Certificate) are included in the Additional Information section of this IRASIMPLE IRAFormDepartment of the TreasuryInternal Revenue ServiceOMB No. 1545-0074W-4P(page 1 of 2)-1998, 2004 Wolters Kluwer Financial Services - Bankers Systems form IRA4/W4P-LAZ Rev. 1/1/2007*Select One. (For further information, see Additional Information included with this form .)

5 Mail check to into myaccount at thisfinancial Amount PaidRecipient InformationImmediate DistributionPeriodic DistributionOther(See IRS form W-8 BEN if you are a foreign person.)notadditionaladditionalNAME, ADDRESS, CITY, STATE AND ZIPA. PAYMENT ELECTIONC. PAYMENT DETAILB. PAYMENT METHODBENEFICIARY DATE OF BIRTH (IF APPLICABLE)IRA ACCOUNT (PLAN) NUMBER (IF APPLICABLE)DAYTIME PHONE NUMBERTAXPAYER IDENTIFICATION NUMBER (TIN)/SSN (IF APPLICABLE)DAYTIME PHONE NUMBERSOCIAL SECURITY NUMBERTYPE OF IRA (SELECT ONE):IRA ACCOUNT (PLAN) NUMBERDATE OF DEATH (IF APPLICABLE)DATE OF BIRTHNAME, ADDRESS, CITY, STATE AND ZIPlllllllllllllllllllllllllllllllllll(c ompleted by financial organization)(amount subject to withholding)(if applicable)lll(page 2 of 2) Retirement , exception , no known Health Savings Account Funding Additional INFORMATIONR ecipient of Federal Income Payments 10% Not to Have Income Tax Your "No Withholding" ChoicePayments to Foreign Persons and Payments Outside the United is a Distribution taken by a beneficiary(ies)

6 Of a deceased IRAowner that is exempt from the premature- Distribution penalty Distribution for disability can avoid the 10 percentpremature- Distribution penalty tax if you are younger than age 59 andmeet the definition of disability under Internal Revenue Code (IRC)Section 72(m)(7).Eligible retirement plans include qualifiedplans under IRC Section 401(a), which includes Section 401(k) plans, atax-sheltered annuity under IRC Section 403(b), or a deferredcompensation plan under IRC Section 457(b).An excess contribution occurs when thecontribution amount exceeds allowable limits or when an ineligibleindividual makes a contribution.

7 For correction purposes, an IRA ownercan treat an unwanted contribution as an you are age 59 or older, you are not subject to a 10 percentpremature- Distribution penalty types of distributions areautomatically exempt from the 10 percent premature- Distribution penaltytax:If you are younger than age 59 , youmay be subject to a 10 percent premature- Distribution penalty tax unlessyou properly roll over the assets within 60 days (or 120 days in the case ofthe return of a first-time homebuyer Distribution ), or unless you meet anexception. The exceptions are for distributions used to pay for a:Violations of IRC Section 4975 due to improperinvestment or use of IRA assets could result in the IRA assets becomingfully taxable and subject to penalty is adistribution from a traditional IRA, not including a SEP or SIMPLE IRA,to the extent it is contributed to your health savings account.

8 The electionto make this Distribution is recharacterization is the method by which an IRAowner can redesignate the type of IRA contribution made for the may revoke your IRA on or before seven (7) days afterthe date of establishment. If you revoke a regular contribution, thedistribution is reported to the IRS as a correction of excess contribution inthe same year. If you revoke a rollover or transfer contribution, thedistribution is reported to the IRS as a normal Distribution if you are age59 or older, or as a premature Distribution no known exception, if youare younger than age 59 .Under Treasury Regulation Section (a)(9)-8,Q&A-3, a separate account in an IRA would be a separate portion of theIRA that reflects a beneficiary's separate interest in the IRA as of the dateof the owner's death.

9 If separate accounting is not immediate upon an IRAowner's death, an IRA custodian/trustee should allocate the post-deathinvestment gains and losses for the period prior to the establishment ofseparate accounts on a reasonable and consistent pro rata basis among theseparate beneficiary transfer is the non-reportable movement of assets betweenIRAs of the same IRA Distribution form for Traditional and SIMPLE IRAs isdesigned to assist you in selecting your individual retirement account (IRA) Distribution reason and law or policies of the IRAcustodian/trustee may require additional documentation. A separatedistribution form must be completed for each Distribution is in your best interest to seek the guidance of atax or legal professional before completing this document.

10 Your first referenceshould be the IRA agreement and disclosure statement you received uponestablishing your IRA or amendments provided by your custodian/trustee. Formore information, refer to Internal Revenue Service (IRS) Publication 590,, IRS Publication 505,, instructions to your federal income taxreturn, your local IRS office, or the IRS's web site at general understanding of the following terms may be helpful incompleting your Distribution subsequently converted to a Roth Distribution made to satisfy an IRS based on an election to receive substantially equalperiodic payments for the greater of a five-year period or until youattain age 59.