Form: IRA Distribution Request

Method 1: Submit Electronically

Fill out the form on the lower half of this page – Click here

OR

Method 2: Print and Mail

Click here to download a PDF of the IRA Distribution Request form.

Screen Shot 2015-05-19 at 11.24.28 AMSend completed form to:

Polish Roman Catholic Union of America
Attn: Annuity Department
984 N. Milwaukee Ave.
Chicago, IL 60642-4101

If you have any questions please contact us online or call 1-800-772-8632


1. Account Information

Certificate (Policy)/ Account Number

2. Annuitant Information

Name*:

Address*:




State:

Home Phone Number*:
() - x

Work Phone Number:
() - x

E-Mail Address*:

Social Security Number/TIN*:

Date of Birth*:
/ /

3. Type of Distribution - Choose only one

NORMAL - Annuitant is over age 59 1⁄2.

PREMATURE- Annuitant is under age 59 1⁄2,is not taking substantially equal payments and acknowledges tax consequences and possible penalties.

ROLLOVER - Annuitant will be directly rolling the proceeds into another IRA or qualified plan with another trustee (funds made payable FBO the annuitant and mailed directly to other trustee).

EARLY - Annuitant is under age 591⁄2 and taking substantially equal payments for the later of five years or until reaching 59 1⁄2.

REQUIRED MINIMUM - My RMD for will be satisfied by a distribution from another IRA.

DEATH - Attach a certified copy of annuitant's death certificate, a form W-9 signed by the beneficiary, and a tax waiver if required by your state.Check here if sole Primary Beneficiary is spouse and to assume ownership:

DISABILITY - Medical certification of disability must be attached, as defined under Section 72(m)(7) of the Internal Revenue Code.

MEDICAL EXPENSES - Proceeds must be used to pay medical expenses exceeding 7.5% of Adjusted Gross Income.

HIGHER EDUCATION EXPENSES - As defined under Section 529(e)(3) of the Internal Revenue Code.

FIRST-TIME HOME PURCHASE - Distributions may not exceed the $10,000 lifetime cap.

EXCESS CONTRIBUTIONS - Redeem excess contribution of $ , , . made for tax year.

4. Distribution Instructions - Choose only one

Lump Sum Distribution (to close account)

Specific Amount: $

Periodic Distribution Payments of required minimum distributions after age 701⁄2 (Complete Sections 6 and 7)

Interest >
For the first distribution, please include interest applied during the following period:
From / Thru /
5. Frequency of Distribution - Choose only one

MonthlyQuarterlySemi-AnnuallyAnnuallyOne-Time

Beginning month and year for the RMD distribution(s): / /

Periodic distributions (other than required minimum distributions after age 70 1⁄2), which exceed, on an annual basis, 10% of the account value at the end of the previous year may be subject to surrender charges as defined in your certificate.
6. RMD Calculation (if selected in Section 3) - Choose only one

Based on Uniform Life Expectant Table
Annuity Owner's date of birth: / /

Based on Joint Life and Last Survivor Expectancy Table
Annuity Owner date of birth: / /
Is the sole primary beneficiary of your spouse? yesno
Spouse's date of birth (if sole primary beneficiary): / /

I request a specific amount for my RMD: $

If you have more than one PRCUA IRA, or if you have another IRA with a different financial institution, then the life expectancy calculation for the above-referenced account may not satisfy the total IRS minimum distribution requirements for annuitants over 70 1/2. Please consult your tax advisor for assistance.
7. Tax Withholding Election - Choose only one

The distributions you take from your IRA are subject to federal income tax withholding unless you elect not to have withholding apply. If you do not select a box below, you are deemed to elect 10% tax withholding.

I elect NOT to have federal income tax withholding. I understand that I am still liable for payment for federal income tax on the distribution received. I also understand that I may be subject to federal income tax penalties under the estimated tax payment rules if my payments of the estimated tax and withholding are insufficient.

Withhold federal income tax rate of % from distributions.

Withhold federal income tax amount of $

8. Payment Information - Choose only one

By check to the mailing address currently on file for this account. By ACH/EFT (Complete Form ACH1)

By check to a third party address (Payable to the owner(s) or FBO the owner(s)):







State:

(please include a completed Annuity Application which is available for download here).

9. Signatures

This form must be signed by the IRA Annuitant (or Beneficiary or Executor for Death Benefits only).

By checking this box, you hereby affirm that the information you have provided is true and correct and that you are aware of all the consequences affecting the distribution requested by this form. This authority is to remain in full force and effect until PRCUA has received written notification from me (or either of us) of its termination in such time and manner as to afford PRCUA a reasonable opportunity to act on it.

Today's Date*:
/ /

Witness

This form requires a witness ONLY if your distribution is to be sent to a third party or to an address different from what we currently have on file for your annuity. Please note that for those types of distributions, the form will not be processed unless a witness signs and dates in the appropriate areas below.

By checking this box, you hereby affirm that you are the witness mentioned above.

* Please verify you are a human:

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