Traditional IRA Withdrawal Request All States
Traditional IRA Withdrawal Request All States
Traditional IRA Withdrawal Request All States
I. Participant/Beneficiary Information
Participant/Beneficiary Name (First) (Middle Initial) (Last) Date of Birth
II. Withdrawal Request (Please note that the Distribution Amounts paid to you will be net of taxes you request to be
withheld and taxes required to be withheld by law.)
Please withdraw from account number _________________________
$_______________________ or
Bank Use Only
Entire balance Disbursed at branch? Yes No
Withdrawal Reason (check one only)
Under age 59 ½
Age 59 ½ or older
Note: If I am age 70 ½ or older and this distribution meets/exceeds my required minimum distribution for the
current year (check one): Cancel remaining scheduled distributions for the current year
Continue scheduled distributions
Disabled as defined in Section 72(m)(7) of the Internal Revenue Code
Death distribution to a beneficiary/executor/trustee/representative
Withdrawing an unwanted or excess contribution on or before the tax filing due date (including extensions)
in the amount of $________________ and the net income (gain or loss*) amount. The excess contribution
was made during the current tax year on this date ________________.
*Treasury Regulations require that we calculate whether there is a gain or a loss on your excess
contribution. If there is a loss, the loss amount will be deducted from the excess contribution amount to be
withdrawn.
Withdrawing an unwanted or excess contribution on or before the tax filing due date (including extensions)
in the amount of $________________ and the net income (gain or loss*) amount. The excess contribution
was made during the previous tax year on this date ____________.
*Treasury Regulations require that we calculate whether there is a gain or a loss on your excess
contribution. If there is a loss, the loss amount will be deducted from the excess contribution amount to be
withdrawn.
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Name ________________________________________________
SSN _______________________
IV. Withholding Election - U.S. Person (U.S. Citizen or Resident Alien) or a Beneficiary that is a U.S. Estate, Trust or Charity
Distributions from a Traditional IRA, Traditional Rollover (Conduit) IRA, SEP-IRA (“IRA”) or SARSEP are subject to
federal and, in some cases, state income tax withholding. Unless you elect otherwise below, 10% of your distribution
amount must be withheld in payment of federal income tax. This election will remain in effect until revoked by you in
writing. If applicable, state income tax must be withheld according to requirements for your state of residence.
Several states require withholding from your distribution if you are subject to federal income tax withholding (AR*, DE,
IA, KS*, ME, MA, MI** NE, NC*, OK, OR**, VT) and may require that a separate election form be completed. Consult
your tax advisor for additional information regarding state income tax withholding.
* State tax withholding applies if federal tax withholding becomes mandatory as a result of failure to opt out of
federal tax withholding. Otherwise, state tax withholding is voluntary if you elect to have federal tax withheld.
** Required unless you opt out of state withholding.
Please note: If you are a U.S. person you are not permitted to opt out of federal income tax withholding if any of
the following applies, and 10% will be withheld unless a greater amount is elected:
1) You are requesting a distribution to be sent outside the U.S., or
2) The address of record on your IRA is outside the U.S. and you are requesting a payment be deposited to
another bank account within the U.S.
Caution: There are penalties for not paying enough federal income taxes during the year, either through withholding
from distributions or by making estimated tax payments. For more information regarding estimated federal income tax
requirements and penalties, please see Publication 505, Tax Withholding and Estimated Tax, available from most IRS
offices or on line at www.irs.gov.
SELECTIONS ARE REQUIRED for both Federal and State Tax Withholding below
A. Regarding federal income tax withholding (If no election is checked below, 10% of your requested
distribution amount will be withheld.)
If permitted I elect to have (check one):
No federal income tax withheld from my distributions.
____% withheld (must be 10% or greater)
$____________ withheld (amount must be 10% or more of the distribution amount)
(continued on next page)
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Name ________________________________________________
Traditional IRA Withdrawal Request
(Continued) SSN _______________________
X__________________________________________________
Signature of Partici
Participant/Beneficiary Date
(Signature below indicates a signature verification has been performed.)
__________________________________________________
Accepted by JPMorgan Chase Bank, N.A. (Custodian) Date
State/Commonwealth of __________________________
County of ______________________________________ } SS.
On this the _____ day of _________________, ______, before me, _______________________________, the undersigned Notary Public, personally
Day Month Year Name of Notary Public
appeared __________________________________, personally known to me or proved to me on the basis of satisfactory evidence to be the person(s)
Name of Signer
whose name(s) is/are subscribed to the within instrument, and acknowledged to me that he/she/they executed the same for the purposes therein stated.
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Name __________________________________________
Traditional IRA Withdrawal SSN _________________
Request (Continued)
31 Retirement Distribution Penalty waived for withdrawal by account owner who is age 59 ½ and older where
the funds are disbursed to the customer via cash, check or deposit or transfer to a
non-IRA account.
32 Remove Excess Penalty waived for withdrawal of an excess annual contribution plus earnings.
<59 ½ - IRS Exception Penalty waived for withdrawal by an account owner who is under age 59 ½ for:
Applies payment of health insurance premiums after separation from employment, medical
33 expenses in excess of 7.5% of adjusted gross income, payment of higher education
expenses, payment of first-time home purchase expenses, substantially equal
periodic payments or due to IRS levy.
Retirement Money Market
35 Penalty doesn’t apply.
Account
36 Court Order Penalty waived due to Court Order.
• I am not conditioning the waiver of the early withdrawal penalty on the customer’s investing in or purchasing an investment or insurance
product or service. I understand that doing so could be a violation of bank anti-tying laws.
Note: Some waiver reasons require supporting documents that must be scanned. For more information, please see Policies & Procedures.
Banker Signature________________________
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