Print Reset Clear

JPMorgan Chase Bank, N.A.

Custodian

TRADITIONAL IRA WITHDRAWAL REQUEST

Use this form to request a withdrawal from a Traditional IRA, Traditional Rollover (Conduit) IRA, Traditional Beneficiary
IRA or SEP-IRA (“IRA”). Complete a separate form for each additional account number and/or distribution reason.

I. Participant/Beneficiary Information
Participant/Beneficiary Name (First) (Middle Initial) (Last) Date of Birth

Residential Street Address City State Zip Code

SSN/Taxpayer ID Number Daytime Phone Number Residency Status

 US Citizen Resident Alien Non-Resident Alien
For state tax purposes my state of residence is: __________________________________
(Required if different from above)

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withdrawn.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withdrawn.

N15185 (03/17) Distribution: Fax to Retirement Services – 866-568-6644 Copy – Participant/Beneficiary Page 1 of 4
Print Reset Clear

Name ________________________________________________
SSN _______________________

Traditional IRA Withdrawal Request

(Continued)

III. Payment Instructions–Deposit Accounts

Payment is to be (check one and complete requested information):

 Paid to me by check  Deposited to my Chase  Checking account number ___________________________
 Savings account number ____________________________

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)

N15185 (03/17) Distribution: Fax to Retirement Services – 866-568-6644 Copy – Participant/Beneficiary Page 2 of 4
Print Reset Clear

Name ________________________________________________
Traditional IRA Withdrawal Request
(Continued) SSN _______________________

B. Regarding state income tax withholding (Complete B(i) or B(ii))

i. All states except California - Complete this part (i) if you reside in a state other than California
I understand the withholding requirements for my state of residence and hereby elect to have (check one):
 No state income tax withheld from my distributions or I certify that I am not subject to state income tax withholding.
 ______% withheld
 $__________ (amount) withheld
 ______% of federal withholding amount withheld
ii. California residents ONLY
Caution: Remember that there are penalties for not paying enough tax during the year, either through withholding or
estimated tax payments. You may be able to avoid paying quarterly estimated tax to the Franchise Tax Board by
having enough tax withheld from your distributions.
I understand the withholding requirements for California and hereby elect to have (check one):
 No California State income tax withheld from my distribution(s) or I certify that I am not subject to California State
tax withholding.
 $__________ This amount which I determined by using the California State wage withholding table.
 _________ % of the requested distribution amount.
 $__________ A specific dollar amount.
 10% of federal tax withholding amount withheld
Important! If no California State tax withholding election is made above, we will withhold 10% of the federal income tax
withholding amount required under part A above. I further understand that certain states require withholding of either
1) a specific minimum percent of my distribution or of my federal tax withholding amount, or 2) an amount in whole dollars
only. By signing below, I authorize the Custodian to adjust the withholding amount or percent requested above to meet those
requirements, if applicable.
NOTE: Withholding for Non Resident Aliens or a beneficiary that is a Foreign Estate, Trust or Charity
If you are a nonresident alien, this form must be accompanied by a properly completed IRS Form W-8BEN with a valid treaty
claim and any necessary supporting documentation, in order to apply any available tax treaty withholding rate for the country of
your permanent residence. If you do not provide a valid treaty claim, we will withhold federal tax at a rate of 30%, as well as
any applicable state tax. If you are a foreign entity, you must provide a treaty claim on the appropriate Form W-8 to certify your
foreign status, along with any necessary supporting documentation.
V. Participant/Beneficiary Acknowledgement
The custodian is authorized and directed to distribute from my account in the manner requested above. I acknowledge that, if a
distribution is made from a retirement CD, an early withdrawal penalty may apply. I further acknowledge that if the distribution
amount requested exceeds the plan balance, my request may not be processed. I understand that this withdrawal can have
important tax consequences and that this distribution and any tax withholding, if applicable, will be reported to the IRS on
Form 1099-R or 1042-S. I understand that I should consult a legal, accounting or tax advisor for questions. I assume full
responsibility for the consequences of this withdrawal. I certify that no tax or legal advice has been given to me by the custodian.
All decisions regarding this withdrawal are my own and I expressly assume all responsibility for the custodian’s execution of these
instructions and hold the custodian harmless of any resulting liabilities.
Participant’s/Beneficiary's signature must be notarized unless signature verification is performed in branch.

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.

WITNESS my hand and official seal.

Signature of Notary Public

Any Other Required Information

(Printed Name of Notary, Expiration Date, etc.)

(Place Notary Seal and/or Stamp Above)

N15185 (03/17) Distribution: Fax to Retirement Services – 866-568-6644 Copy – Participant/Beneficiary Page 3 of 4
Print Reset Clear
Name __________________________________________
Traditional IRA Withdrawal SSN _________________
Request (Continued)

THIS SECTION FOR BANK USE ONLY

Transaction Detail
Does this close the account? Yes (Tran Code 98) No (Tran Code 90)
Total Paid to Participant/Beneficiary $______________ Method of Payment
Check #___________________ $______________
Checking #________________ $______________
Monetary Details
Savings # _________________ $______________
Principal Amount Withdrawn $______________
IRA # ____________________ $______________
Accrued Interest Withdrawn $______________
Penalties Charged $______________ Penalty Code _____ (see chart)
Federal Income Tax Withheld $______________
State Income Tax Withheld $______________ State Code _____

CD EARLY WITHDRAWAL PENALTY CODES

Penalty
Title Description
Code
00 Penalty Assessed Penalty applied and charged.
01 Death Penalty waived due to the death of an account owner.
06 Withdrawal at Maturity Penalty doesn’t apply.
07 Disability Penalty waived due to the disability of the account owner.
Withdrawal – Interest Penalty waived for withdrawal of interest only.
08
Only
Legal Incompetence Penalty waived for withdrawal due to judicial determination of account owner’s legal
09
incompetence.

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.

Banker must attest to the following for distribution to be processed

• 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________________________

REQUIRED BRANCH/DEPARTMENT INFORMATION

Bank No. Mail Code Cost Center No. Date
252594
Employee Name Telephone No.
866/780-4978

N15185 (03/17)
Distribution: Fax to Retirement Services – 866-568-6644 Copy – Participant/Beneficiary Page 4 of 4