Individual Retirement Account Distribution Request Form For

Virtus Mutual Funds
PO Box 9874
Providence RI 02940-8074
Individual Retirement Account
Distribution Request Form
For assistance, please contact us at 1-800-243-1574 or visit our website at Virtus.com
This form is not intended for required minimum distributions, trustee to trustee transfers, recharacterizations, or conversion requests.
1. Account Information
Shareholder Name
Date of Birth
U.S. Social Security Number
Address
Daytime Phone Number
Email Address
City, State, ZIP Code
Account Number
2. Type of Account
Traditional/Rollover IRA
SEP IRA
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.
3. Reason for Distribution
A. From a Traditional, Rollover or SEP IRA
This distribution is being made for the following reason (check one):
1. Normal Distribution - You are age 59 ½ or older.
2. Early (Premature) Distribution - You are under age 59 ½, including distributions due to medical expenses, health insurance
premiums, higher education expenses, first time home buyer expenses, or other reasons.
3. Substantially equal periodic payments within the meaning of section 72(t) of the Internal Revenue Code.
4. Permanent disability - You certify that you are disabled within the meaning of section 72(m)(7) of the Internal Revenue Code.*
5. Removal of excess - You must complete Section 4 (Excess Contribution Election) in its entirety.
6. 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.
7. Qualified Reservist Distribution
8. Transfer incident due to divorce or legal separation – Contact Shareholder Services regarding additional document requirements.
B. Qualified Distribution from a Roth IRA
This Roth IRA distribution satisfies the 5-year holding period requirement:
Yes (If "No", proceed to Section C)
This distribution is being made for the following reason (check one):
1. Normal distribution - You are age 59 ½ or older.
2. 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.
C. Non-Qualified Distribution from a Roth IRA
This distribution is being made for the following reason (check one):
1. Normal Distribution (prior to the 5-year holding requirement) - You are age 59 ½ or older.
2. Early (Premature) Distribution - You are under age 59 ½, including distributions due to medical expenses, health insurance
premiums, higher education expenses, first time home buyer expenses, or other reasons.
3. Substantially equal periodic payments within the meaning of section 72(t) of the Internal Revenue Code.
4. Permanent disability - You certify that you are disabled within the meaning of section 72(m)(7) of the Internal Revenue Code.*
5. Removal of excess - You must complete Section 4 (Excess Contribution Election) in its entirety.
6. Qualified Reservist Distribution
7. Transfer incident due to divorce or legal separation– Contact Shareholder Services regarding additional document requirements.
*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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4. Excess Contribution Election
Amount of excess: $_________________________ Tax year for which the excess 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 your federal income tax-filing deadline (including extensions):
Remove excess plus/minus net income attributable. Distribute according to my instructions in Section 6 (Distribution Instructions).
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 your federal income tax-filing deadline (including extensions). Earnings on the excess
contribution will remain in the account.
Remove excess and distribute according to my instructions in Section 6 (Distribution Instructions).
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 & B
A. Choose one:
Liquidate entire account.
One-Time Partial Distribution of $______________________________
Periodic Distributions of $_____________________________________ to be distributed at the following frequency:
Monthly
Quarterly
Semi-Annually
Annually
Beginning _____________________________________ (month/year)
I elect to take periodic distributions on the _______________ day of the month. If no selection is made, withdrawals will run on or about
the 15th of the month.
*Substantially Equally Periodic Payments (Section 72(t) of the Internal Revenue Code) – In the amount of $______________________ or
Calculate under the RMD method using
Uniform Lifetime Table
Single Life Table
Joint and Last Survivor Table*
*Beneficiary's Name:_____________________________________________________ Date of Birth: ________________________________
Frequency of distributions:
Monthly
Quarterly
Semi-Annually
Annually
Beginning _____________________________________ (month/year)
I elect to take periodic distributions on the _______________ day of the month. If no selection is made, withdrawals will run on or about
the 15th of the month.
B. Choose one:
Distribute proportionally across all funds, (or)
Distribute as indicated below:
Fund: __________________________________________________
Amount: $ ____________________
or Percentage: _____________%
Fund: __________________________________________________
Amount: $ ____________________
or Percentage: _____________%
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
Effective January 1, 2015, an IRA participant will be 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 trusteeto-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”, “Announcement 2014-15 or
“Announcement 2014-32”. You must contact the receiving institution to initiate a trustee-to-trustee transfer.
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6. Distribution Instructions
Based on your selected delivery method, a signature guarantee stamp may be required. Please refer to your prospectus, the Signature
Guarantee section of this form or call us at the number listed on this form for specific requirements.
If a payment method is not selected, or you selected a method that requires a signature guarantee and you did not obtain the stamp,
your payment will be issued as a check payable to you and mailed to your address of record. Your delivery method will remain in effect
until we receive notice from you requesting a change.
A. Distribution by Mail – Checks are generally mailed within two business days.
Name and address on the account, or
Special Payee below (Signature Guarantee required)
Mail for Deposit - Check will be made payable to the registered IRA account owner and mailed to the following address.
Qualified Plan, 401(k), TSP or 403(b) Direct Rollover Deposit – Check will be made payable to the receiving custodian and
mailed to the following address. Please be sure to include the applicable account number.
___________________________________________________________________________________________________________________________________
Special Payee Name / Receiving Custodian
___________________________________________________________________________________________________________________________________
Special Payee Address
B. Direct-to-Bank Distributions (Signature Guarantee required)
One-Time Distribution - May be sent to your bank electronically using one of two methods. ACH will be considered the default method if an
election is not made. Choose one:
Federal Fund Wire – Initiates the next business day. This option is NOT intended for trustee to trustee transfers. Please check with
the receiving custodian for alternative payment instructions. Your bank may charge a fee for this service.
Automated Clearing House (ACH) – Initiates within one to three business days.
Periodic Distributions – Periodic distributions will be sent through the Automated Clearing House (ACH) - IMPORTANT: The form must be
submitted at least 10 business days prior to the first transaction for the banking information to be properly verified. If the banking
information has not been verified prior to the draft, a check will be issued for that payment.
Please complete the following section and include a preprinted VOID check to have your withdrawals electronically transmitted to your checking
account (no starter checks) or a letter from the bank, on bank letterhead confirming the banking information, to have the withdrawals
electronically transmitted to your savings account.
If you wish to have the banking information added to your account for future transactions, please check the following box: ___________________________________________
_____________________________________________
________________________________________
Bank Name
Bank Routing Number
Account Type (Checking or Savings)
___________________________________________
_____________________________________________
________________________________________
Bank Account Holder’s Name(s)
Bank Account Number
Bank Telephone Number
ATTACH VOIDED CHECK HERE
C. Purchase into Non-Retirement Account (Signature Guarantee required if the receiving account is not solely in the name of the shareholder)
Purchase into my existing non-retirement account. Account Number:____________________________________________________
Invest proportionally across all fund(s) (or) Invest in (Fund Name): ___________________________________________________
Purchase into new non-retirement account – Attach a completed New Account Application with investment instructions.
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7. Taxes
Federal Tax Withholding Election
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.
Do NOT withhold federal income tax. (This option is only available for accounts registered with an address in the United States.)
Withhold 10% federal income tax.
Withhold __________% federal income tax (must be more than 10%)
State Income Tax Withholding Election
Your state of residence will determine your state income tax withholding requirements, if any. Those states with mandatory withholding will
require state income tax to be withheld from payments if federal taxes are withheld. Voluntary states let individuals determine whether they
want state taxes withheld. Some states have no income tax on retirement payments. You may wish to consult with a tax advisor or your state's
tax authority for additional information on your state requirements.
I elect NOT to have state income tax withheld from my retirement account distributions (only for residents of states that do not require
mandatory state withholding).
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 withholding) $_____________________________________________ or __________________%
8. Authorizing Signature
I certify that I am the Participant authorized to make these elections and that all information provided is true and accurate. I further certify that
the Custodian, the Virtus Mutual Funds, or any employee, officer, director/trustee or 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, Virtus Mutual Funds and the employees,
officers, directors/trustees and agents of each 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,
Virtus Mutual Funds and the employees, officers, directors/trustees and agents of each shall be indemnified and held harmless, for any tax,
legal or other consequences resulting from my election(s). The Custodian is hereby authorized and directed to distribute funds from my
account in the manner requested. I have read and understand and agree to be legally bound by the terms of this form.
_________________________________________________
_________________________________________________
_______________________
Print Name
Signature
Date
9. Signature Guarantee
A Medallion Guarantee is required for lump sum distributions that meet the following criteria: Distributions that are being sent to a bank
account (not currently maintained on the account), the redemption check is to be made payable to someone other than the shareholder and/or
mailed to an address not presently on our records, the distribution exceeds $50,000.00, the address on the account has been updated within 30
days.
An SVP (Signature Validation Program) Stamp* is required for the following circumstances: Withdrawals under a Systematic Withdrawal
Plan are to be sent to a bank account, mailed in check form to a special payee or if the funds are to be exchange to an account not solely
registered to the shareholder.
Place Stamp Here
A Medallion Guarantee Stamp may be obtained from an eligible guarantor.
Eligible guarantors include Commercial Banks, Trust Companies, Savings
Associations and Credit Unions, as defined by the Federal Deposit Insurance Act
and registered Broker/Dealers.
An SVP (Signature Validation Program) Stamp may be obtained from eligible
members of the Medallion Guarantee Program, including banks, Broker/Dealers,
credit unions, national securities exchanges, registered securities associations,
clearing agencies and savings associations.
*In the event your bank or financial institution does not participate in the SVP
Stamp program, we will accept a Medallion Guarantee.
Notarization from a Notary Public is not acceptable.
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