Individual Retirement Account (IRA) Distribution Request Form

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Individual Retirement Account (IRA)
Distribution Request Form
This form is not intended
for required minimum
distributions, trustee
to trustee transfers,
recharacterizations, or
conversion requests.
1Participant Information
(Please print)
Name
Daytime Phone
Address
City
StateZIP Code
Social Security Number
Date of Birth
Account Number
Complete the following if you are a beneficiary requesting a full liquidation of the inherited proceeds.
Beneficiary Name
Daytime Phone
Social Security Number
Date of Birth
2Type of Account
o Traditional IRA/Rollover IRA
o SEP-IRA o Roth IRA (Proceed to Section 3- B or C)
Note: For trustee to trustee transfers, please complete the appropriate receiving custodian’s trustee to trustee transfer form.
This form is not intended to facilitate a beneficiary/inherited IRA transfer due to death. For revocations, refer to the Traditional
and Roth Individual Retirement Account (IRA) Combined Disclosure Statement for instructions and information regarding your
revocation rights. All required documentation must be received in good order before the distribution request can be honored.
All legal documents must be certified and a Medallion Signature Guarantee may be required. Please see the Participant
Authorization Section for an explanation of the Medallion Signature Guarantee.
3Reason for Distribution
A. FROM A TRADITIONAL, ROLLOVER OR SEP IRA
The distribution is being made for the following reason (check one):
o1. Normal distribution—You are age 59½ or older.
o2. Early (premature) distribution—You are under age 59½, including distributions due to medical expenses, health insurance
premiums, higher education expenses, first time homebuyer expenses, or other reasons.
o3. Substantially equal periodic payments within the meaning of section 72(t) of the Internal Revenue Code.
o4. Death/Beneficiary liquidation—If you are a beneficiary, contact Shareholder Services regarding additional document requirements.
o5. Permanent disability—You certify that you are disabled within the meaning of section 72(m)(7) of the Internal Revenue Code.*
o6. Transfer incident due to divorce or legal separation. Contact Shareholder Services regarding additional document requirements.
o7. Removal of excess—You must complete Section 4 (Excess Contribution Election) in its entirety.
o8. Direct rollover to a qualified plan 401(k), TSP or 403(b)—You are certifying that the receiving custodian will accept the
IRA assets issued.
o9. Qualified Reservist Distribution
B. QUALIFIED DISTRIBUTION FROM A ROTH IRA
This Roth IRA distribution satisfies the 5-year holding period requirement:
The distribution is being made for the following reason (check one):
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IRADIS 0516
Yes
(If “No”, proceed to Section C)
o1. You are age 59½ or older.
o2. Death/Beneficiary liquidation—If you are a beneficiary, contact Shareholder Services regarding additional document requirements.
o3. Permanent disability­—You certify that you are disabled within the meaning of section 72(m)(7) of the Internal Revenue Code.*
Note: Distributions not meeting the 5-year required period and for all other reasons not listed above are considered non-qualified.
*For purposes of section 72(m)(7), an individual shall be considered to be disabled if he is unable to engage in any substantial gainful activity by reason of any
medically determinable physical or mental impairment which can be expected to result in death or to be of long-continued and indefinite duration.
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C. NON-QUALIFIED DISTRIBUTION FROM A ROTH IRA
The distribution is being made for the following reason (check one):
o1. Normal distribution (prior to the 5-year holding requirement)—You are age 59½ or older.
o2. Early (premature) distribution—You are under age 59½, including distributions due to medical expenses, health insurance
premiums, higher education expenses, first time homebuyer expenses, or other reasons.
o3. Substantially equal periodic payments within the meaning of section 72(t) of the Internal Revenue Code.
o4. Death/Beneficiary liquidation—If you are a beneficiary, contact Shareholder Services regarding additional document requirements.
o5. Permanent disability—You certify that you are disabled within the meaning of section 72(m)(7) of the Internal Revenue Code.*
o6. Transfer incident due to divorce or legal separation. Contact Shareholder Services regarding additional document requirements.
o7. Removal of excess—You must complete Section 4 (Excess Contribution Election) in its entirety.
o8. Qualified Reservist Distribution
*For purposes of section 72(m)(7), an individual shall be considered to be disabled if he is unable to engage in any substantial gainful activity by reason of any
medically determinable physical or mental impairment which can be expected to result in death or to be of long-continued and indefinite duration.
4.Excess Contribution Election
Amount of excess: $
Tax year for which excess contribution was made:
Date deposited:
Earnings will be removed with the excess contribution if corrected before your federal income tax-return due date (including
extensions), pursuant to Internal Revenue Code Section 408(d)(4) and Internal Revenue Service (“IRS”) Publication 590. You
may be subject to an IRS penalty of 6% for each year the excess remains in the account. In addition, the IRS may impose a 10%
early distribution penalty on the earnings, if you are under age 59½. You will receive IRS Form 1099-R for the year in which the
excess distribution takes place (not for the year in which the excess contribution was made). Consult IRS Publication 590 for more
information pertaining to excess contributions. If you are subject to a federal penalty tax due to an excess contribution, you must
file IRS Form 5329.
For the purpose of the excess contribution, we will calculate the net income attributable (“NIA”) to the contribution using the
method provided in the IRS Final Regulations for Earnings Calculation for Returned or Recharacterized Contributions. This method
calculates the NIA based on the actual earnings and losses of the IRA during the time it held the excess contribution. Please note
that a negative NIA is permitted and, if applicable, will be deducted from the amount of the excess contribution.
A. The excess is being corrected before my federal income tax filing deadline (including extensions):
o Remove excess plus/minus net income attributable. Distribute according to my instructions in Section 6 (Mailing Instructions).
o Remove excess plus/minus net income attributable. Re-deposit as a current year contribution (not to exceed annual IRA contribution limit).
B. The excess is being corrected after my federal income tax filing deadline (including extensions). Earnings on the excess
contribution will remain in the account.
o Remove excess and distribute according to my instructions in Section 6 (Mailing Instructions).
o Remove excess and re-deposit as a current year contribution (not to exceed annual IRA contribution limit).
C. Redesignating an excess contribution to a later tax year. Please consult a tax advisor to review your specific situation and
to determine your best course of action. If you should decide to carry over the excess contribution to a later year, DO NOT
RETURN THIS FORM.
5.Distribution Amount
(Complete Sections A and B)
A. Choose one:
oLiquidate Entire Account
oOne-Time Partial Distribution of $
oPeriodic Distributions—In the amount of $
oMonthly oQuarterly oSemi-Annual o Annual Installments
oSubstantially Equal Periodic Payments (Section 72(t) of the Internal Revenue Code)­— In the amount of $
(or)
Calculate under the RMD method using oUniform Lifetime Table oSingle Life Table oJoint and Last Survivor Table*
*Beneficiary’s Name:
Date of Birth:
Distribute in a series of oMonthly oQuarterly oSemi-Annual o Annual Installments
B. Choose one:
o Distribute proportionately across all funds, (or)
o Distribute as indicated below:
Fund:
Amount: $
or Percentage:
%
Fund:
Amount: $
or Percentage:
%
Fund:
Amount: $
or Percentage:
%
Total Amount: $
Total 100%
IMPORTANT CHANGES TO THE RULES GOVERNING INDIRECT (60-DAY) ROLLOVERS BETWEEN IRA ACCOUNTS
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Effective January 1, 2015, there is a new restriction on indirect (60-day) IRA-to-IRA rollovers. An IRA participant is allowed only one rollover across
all IRAs (Traditional, Rollover, Roth, SEP, SARSEP and SIMPLE IRAs) in aggregate that a taxpayer owns in any 12-month or 365-day period. As an
alternative, a participant can make an unlimited number of trustee-to-trustee transfers where the proceeds are delivered directly to the receiving
financial institution, successor custodian or trustee. For more information please visit the Internal Revenue Service’s web site www.irs.gov using
the search term “IRA One-Rollover-Per-Year Rule”. You must contact the receiving institution to initiate a trustee-to-trustee transfer.
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6.Mailing Instructions
*A Medallion
Signature Guarantee
(“MSG”) Stamp
is required if the
banking instructions
are not already on
file. An MSG may
be obtained at your
local bank or trust
company, securities
broker/dealer, clearing
agency or savings
association. The bank
account must include
your name in the
account registration.
o Mail to my address of record—(if you elected a Direct Rollover to a qualified plan or 403(b) you must complete the receiving custodian below*)
o *Qualified Plan, 401(k), TSP or 403(b) Direct Rollover Deposit—Check will be made payable to the receiving custodian.
Type of plan receiving IRA assets: o 401(k) o 403(b) o TSP o 457 plan oother employer sponsored qualified plan
*Receiving Custodian
Street Account Number
City
State
o *Transfer funds electronically via ACH (voided check required, if not on file)
Name of Institution
Routing and Account Number
Street State
City
o Purchase into my non-retirement account:
o Application attached with investment instructions
o Existing Account Number:
Zip
(or) o *Mail check to:
Zip
(or)
Investment Fund(s):
7.Tax Withholding Election
A. Federal Withholding
Federal income tax will be withheld at the rate of 10% from any distribution, subject to the IRS withholding rules, unless you elect
or have previously elected out of withholding. Tax will be withheld on the gross amount of the payment even though you may be
receiving amounts that are not subject to withholding because they are excluded from gross income. This withholding procedure
may result in excess withholding on the payments. If you elect to have no federal taxes withheld from your distribution, or if you do
not have enough federal income tax withheld from your distribution, you may be responsible for payment of estimated tax. You may
incur penalties under the estimated tax rules if your withholding and estimated tax payments are not sufficient. If you are completing
this form, your below election will remain in effect until such time as you make a different election in writing to the Custodian.
Please select one of the following:
o I elect TO NOT have federal income tax withheld. (This option is only available for accounts registered with an address in the United States.)
o Withhold 10% federal income tax
o Withhold
% federal income tax (must be more than 10%)
B. State Withholding
Your state of residence will determine your state income tax withholding requirements, if any. Those states with mandatory withholding may require state income tax to be withheld from payments if federal income taxes are withheld or may mandate a fixed
amount regardless of your federal tax election. Voluntary states let individuals determine whether they want state taxes withheld.
Some states have no income tax on retirement payments. Please consult with a tax advisor or your state’s tax authority for additional
information on your state requirements.
o I elect TO NOT have state income tax withheld from my retirement account distributions (only for residents of states that do not require mandatory state tax withholding).
o I elect TO have the following dollar amount or percentage from my retirement account distribution withheld for state income taxes (for residents of states that allow voluntary state tax withholding). $
or
%
Mail to the following:
First Class Mail:
Matthews Asia Funds
P.O. Box 9791
Providence, RI 02940
Overnight Mail:
Matthews Asia Funds
4400 Computer Dr.
Westborough, MA
01581-1722
800.789.ASIA (2742)
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IRA Distribution
Request Form
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8. Participant Authorization
I certify that I am the individual authorized to make these elections and that all information provided is true and accurate. I further
certify that the Custodian, Matthews Asia Funds, or any agent of either of them has given no tax or legal advice to me, and that
all decisions regarding the elections made on this form are my own. The Custodian is hereby authorized and directed to distribute
funds from my account in the manner requested. The Custodian may conclusively rely on this certification and authorization
without further investigation or inquiry. I expressly assume responsibility for any adverse consequences which may arise from
the election(s) and agree that the Custodian, Matthews Asia Funds, and their agents shall in no way be responsible, and shall be
indemnified and held harmless, for any tax, legal or other consequences of the election(s) made on this form.
X
Participant’s Signature*:Date
*Beneficiary’s Signature for inheritance liquidations.
Please review the Matthews Asia Funds prospectus for Medallion
Signature Guarantee stamp requirements.
Medallion Signature Guarantee—Medallion Stamp*
Medallion Signature Guarantee Stamp and Signature: An eligible
guarantor is a domestic bank or trust company, securities broker/
dealer, clearing agency or savings association that participates in
a medallion program recognized by the Securities Transfer Agents
Association. The three recognized medallion programs are the
Securities Transfer Agents Medallion Program (known as STAMP),
Stock Exchanges Medallion Program (SEMP), and the Medallion
Signature Program (MSP). A notarization from a notary public is
NOT an acceptable substitute for a signature guarantee.
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