FORM ID IRA DISTRIBUTION ELECTION REQUEST Section I

Account Number
I.E. Code
FORM ID
IRA DISTRIBUTION ELECTION REQUEST
Section I. Payee Information
Name:
Address:
City:
State:
Marital Status
Citizenship
Date of Birth
SSN / TID #
Zip:
Section II. Reason for Distribution
Premature Distribution (under age 59 ½)
Convert in part or total to Roth IRA – Code 07 or Code 02
Premature Distribution (exception to early withdrawal
penalty applies - under age 59 ½. Must attach certification
form for substantially equal IRA payments) Code 02
Disability Distribution (attach proof of disability) Code 03
Death Distribution(attach copy of death certificate) Code 04
Roth Distribution (under age 59 ½) – Code J
Roth Distribution (over age 59 ½) – Code T
SIMPLE Distribution before 2 years – Code S
Direct Rollover to Qualified Plan from IRA (proof QP will
accept conduit IRA assets) – Code G*
Normal Distribution (over age 59 ½) – Code 07
Coverdell ESA Distribution
Excess Contribution for tax year
Other (specify):
Domestic Distribution (attach copy of court order)
* Indicates distribution must be paid from Corporate LA office
Section III. Type of Distribution (Check only one of the four options below)
1.
Account Termination ($75 termination fee for clients under age 59 ½)
2.
Partial One-time Distribution of:
Credit Balance
Payment of $
, (indicate Gross amount) and/or
Order out the following securities:
3.
Fixed Amount Periodic Automatic Payments:
Recurring:
Monthly
Beginning Date:
Amount of:
4.
8030
Quarterly
-
$
Semi-Annually
Annually
OR
Credit Balance
Dividends
Interest
CreditPlus Checkwriting Program (must also complete CreditPlus Account application)
In order to qualify for the IRA checkwriting privileges, you must be the original account Participant, be at least
59 ½ years of age, and elect to have NO Federal income tax withholding.
0205
Account Number
I.E. Code
FORM ID (page 2 of 2)
IRA DISTRIBUTION ELECTION REQUEST
Section IV. Method of Payment (Check one method only)
Mail to account address of record
Wire funds (must provide wire instructions - $20 wire fee
applies)
Mail to Alternative Address as indicated on this form
ACH (must attach copy of ACH setup form)
Reclassify excess contribution to year
(IRA holder may be subject to 6% penalty; must file form 5329
Journal to WMS Account #
Section V. Notice and Election on Income Tax Withholding (Form W-4P/OMB No. 1545-0415)
Federal Income Tax will automatically be withheld at a rate of 10% unless otherwise specified below:
I am a US Citizen living abroad or I am a non-resident alien
I do not want to have Federal Income Tax withheld from my distribution
Withhold Federal Income Tax as follows:
%
or
IF CALIFORNIA RESIDENT:
State income tax will automatically be
withheld at the rate of 10% of the amount
of federal tax withholding unless otherwise
specified below:
IF OREGON RESIDENT:
State income tax will automatically be
withheld at the rate of 8% unless otherwise
specified below (minimum withholding of
$10.00):
I do not want to have CA State Income
Tax withheld from my distribution
I do not want to have OR State Income
Tax withheld from my distribution.
$
IF WISCONSIN RESIDENT:
State income tax will not be withheld
unless requested by you below:
Withhold WI State Income Tax
withheld from my distribution as follows:
$
or
Withhold CA State Income Tax as
follows: $
Withhold OR State Income Tax as
%
follows: $
Section VI. Attestation and Signatures
I attest to the accuracy of the information stated hereon. I am aware of and accept full responsibility for the tax consequences
respecting these instructions.
X
Payee’s Signature
Date
Spouse’s Signature if resident of a community property state:
AZ, CA, ID, LA, NV, NM, TX, WA, WI
Date
X
X _________________________________________________
Sales Office Approval, Notarization or Signature Guarantee
Date
FOR WMS RETIREMENT SERVICES DEPARTMENT USE ONLY
Gross Distribution
Amount $
Tax
Withheld: $
% Tax Withheld:
Payment Code
IRS Code
Fee $
Processed by
8030
Net Distribution
Amount $
Date
0205