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PO BOX 7080, SAN CARLOS, CA 94070 | TEL: 800-248-8447 | FAX: 650-591-2168 | WWW.IRASERVICES.COM
Dear Representative: Thank you for your interest in using IRA Services Trust Company for your client’s Individual Retirement Account.
This document will assist you in preparing the documents for your client. The information provided on the Account Application will be used to fill-in the other forms where applicable. Please review all forms for additional unique information required and complete them before sending the documents to IRA Services.
To open the account, complete and return the following (make copies for your client):
A c c o u n t A p p l i c a t i o n : The instructions for completing the document are attached to the application. Complete all sections of the application. Incomplete applications will be returned prior to opening the account. Your client must attach a legible copy of a current government issued picture identification card or document (such as a driver's license or passport).
F e e s : Include the Establishment Fee and first year Annual Account Fee. Fees must be included to open the account.
B e n e f i c i a r y D e s i g n a t i o n : Complete this form to designate your client’s beneficiaries.
T r a n s f e r A u t h o r i z a t i o n : Complete this form only if your client will fund this account with a transfer of funds from another IRA.
I n v e s t m e n t A u t h o r i z a t i o n : Complete this form to indicate in what asset your client wishes to invest. Attach any investment instruction page(s) or subscription agreements required. Remember, that a minimum balance must be kept in your custodial cash account and will reduce the available cash for investment.
R e p r e s e n t a t i v e A u t h o r i z a t i o n : Complete this form if your client authorizes you to have access to their account information and to be able to discuss the account with our customer service representatives.
I n t e r n e t A c c e s s R e q u e s t : Complete this form if your client would like to have online access to their account.
Provide the following documents to your client (along with the copies above):
I n v e s t o r C o v e r L e t t e r
F e e S c h e d u l e & F i n a n c i a l D i s c l o s u r e
P r i v a c y N o t i c e
C u s t o d i a l A g r e e m e n t : Please download and provide the appropriate custodial agreement for the type of account your client is opening (i.e. Traditional, Roth, SEP, SIMPLE, Coverdell ESA).
I n t e r n e t A c c e s s T e r m s & C o n d i t i o n s
Optional form you may wish to complete:
R e p r e s e n t a t i v e I n t e r n e t A c c e s s : Complete and return this form to request access to your client’s account, if authorized. Also retain a copy of the Internet Access Terms & Conditions for your file.
If you have any questions, please call our Customer Service Team at 800-248-8447. Sincerely, IRA Services Trust Company
PO BOX 7080, SAN CARLOS, CA 94070 | TEL: 800-248-8447 | FAX: 650-591-2168 | WWW.IRASERVICES.COM
P L A N N I N G F O R Y O U R F U T U R E
W I T H A N A C C O U N T
A T I R A S E R V I C E S
Dear IRA Investor:
Thank you for your interest in opening an Individual Retirement Account with IRA Services. We look forward to working with you in preparing for your retirement.
To open your account you must complete and return the following:
A c c o u n t A p p l i c a t i o n : The instructions for completing the document are attached to the application. Complete all sections of the application. Incomplete applications will be returned prior to opening your account. You must attach a legible copy of a current government issued picture identification card or document (such as a driver's license or passport). You should make a copy of the application for your files. Return the original and ID copy along with the setup fee, first year annual fee and your investment funds.
B e n e f i c i a r y D e s i g n a t i o n : Complete this form to designate your beneficiaries.
T r a n s f e r A u t h o r i z a t i o n : Complete this form only if you are planning to fund this account with a direct transfer of funds from another IRA or retirement account. Attach it to your application if used.
I n v e s t m e n t A u t h o r i z a t i o n : You must complete this document to indicate what investment you want the account to purchase. You may omit this document if you have attached the investment instruction page(s) or subscription agreement from the investment offering.
R e p r e s e n t a t i v e A u t h o r i z a t i o n : If you would like to authorize your representative to have access to your account information and to be able to discuss your account with customer service, please complete this form and return it with your application
Retain the following documents for your files:
F e e S c h e d u l e & F i n a n c i a l D i s c l o s u r e : This document outlines the fees associated with your account and should be retained in your files.
P r i v a c y N o t i c e : This is our privacy statement. You should read it and retain it in your files.
C u s t o d i a l A g r e e m e n t : This is the custodial agreement between you and the custodian for your account. You should retain it for your files.
I R S P u b l i c a t i o n 5 9 0 B o o k l e t : You may obtain a copy of IRS Publication 590 from the IRS by calling 1-800-829-1040 or by accessing their website at www.irs.gov and downloading the publication.
If you have any questions, our Customer Service Team can help you with your new IRA. Call us at 800-248-8447.
Sincerely, IRA Services Trust Company
IMPORTANT INFORMATION ABOUT OPENING YOUR ACCOUNT
To help the government fight the funding of terrorism and money laundering activities, the U.S. Federal law, including the USA Patriot Act of 2001, requires that financial institutions obtain, verify and record certain identifying information from an individual seeking to open a new account. We are required to obtain and verify name, address, date of birth and other information that will allow us to identify you.
NEW ACCOUNT APPLICATION
Mail ORIGINAL form to (fax and/or e-mail copies will NOT be accepted): PO Box 7080, San Carlos CA 94070 | Overnight Mail: 1160 Industrial Rd, Ste 1, San Carlos CA 94070 For inquiries, call: 800-248-8447 or visit www.IRAServices.com
A. PARTICIPANT IDENTIFICATION
NAME/ LAST FIRST MIDDLE
BIRTH DATE
STREET ADDRESS SOCIAL SECURITY NUMBER
CITY STATE ZIP
HOME TELEPHONE
E-MAIL ADDRESS
DAYTIME TELEPHONE
B. PHOTO IDENTIFICATION Please attach a legible copy of your current government-issued photo ID
TYPE OF ID (i.e. Driver’s License, Passport, etc.)
ID NUMBER ISSUING JURISDICATION (Federal, State, etc.) EXPIRATION DATE ISSUE DATE (optional)
C. ESTABLISHING YOUR ACCOUNT Designate Account Type: (check only one) + Traditional* + Roth* + SEP (see instructions) + SIMPLE (see instructions)
Required opening fees: Please refer to the FEE SCHEDULE. You must include a check for fees payable to IRA Services for the Establishment Fee AND the first year Annual Account Fee.
* If this is a beneficial account where you are the beneficiary, please complete a SUPPLEMENTAL ACCOUNT INFORMATION form and attach it to this application.
Fund Your Account: (check all that apply)
+ I will rollover cash from an existing IRA or qualified retirement plan - This will be a Rollover of a distribution from a prior IRA or of a lump sum distribution or plan termination distribution paid to me within one taxable year from a qualified employee benefit plan or annuity, either of which is contributed to this IRA within 60 days of receipt of such funds.
Prior Custodian Plan Name: ____________________________________________________________ Expected Rollover Amount: $_________________
+ I will transfer assets from another IRA and have attached a TRANSFER AUTHORIZATION form
+ I have attached a contribution check as follows: (please also complete & attach a DEPOSIT INFORMATION form)
+ IRA Cash Contribution for the Year: _______ in the amount of: $_________________
+ IRA Cash Contribution for the Year: _______ in the amount of: $_________________
+ Employer OR Employee (circle one) SEP/SIMPLE Contribution for the Year: _______ in the amount of: $_________________
D. DESIGNATION OF YOUR BENEFICIARY Complete and attach an IRA Services’ Beneficiary Designation Form. Use as many pages as necessary. Each page must be complete, signed by you and dated. You must show the percentage share each beneficiary is to receive and the percentages must add to 100% for each type of beneficiary, primary or secondary. In community or marital property states, if anyone other than the spouse is named as primary beneficiary, the spouse must sign all beneficiary designation forms.
E. MAKING YOUR INVESTMENT When you are ready to make your investment complete and send an Investment Authorization Form and any documents required by the investment provider.
F. ACKNOWLEDGMENT & SIGNATURE IRA Services Trust Company Tax ID: 26-2627205 I hereby acknowledge the following: • That the retirement plan I am establishing is self-directed and that I am solely responsible for the success or failure of my investments. • That IRA Services Trust Company is the designated IRA Custodian and IRA Services Inc. is the Administrator. • That I have read and understand the IRA Custodial Agreement and Fee Schedule. • That with the exception of deposits in amounts under $250,000 held at a depository institution and/or other similar banking institutions, my investments are: (a) not insured by the FDIC or any other federal or state deposit
guaranteed fund; (b) not guaranteed by IRA Services Trust Company, its subsidiaries, parent, and/or agents; and (c) are subject to investment risk, including the possible loss of the principal invested. • That certain investments or classes of investments may pose administrative burdens and, therefore, the Custodian and/or Administrator reserve the right not to process or accept such investments. The decision not to act upon
investment directions which the Custodian and/or Administrator determines to be unacceptable for administrative reasons should in no way be construed as a determination concerning the prudence or advisability of investing in the asset.
• My account is subject to an Arbitration provision that appears in the IRA Agreement. • I hereby give my consent to the Custodian and/or Administrator to the following: (a) have my telephone conversations recorded, (b) accept e-mail as a form of written communication and (c) accept faxed investment
authorizations. • I hold harmless, protect and indemnify the Custodian and Administrator from and against any and all liabilities, losses, damages, expenses and charges, including but not limited to attorney's fees and expenses of litigation, which
the Custodian and Administrator may sustain or might sustain resulting directly or indirectly from my investment direction or those received from my authorized financial representative and/or agent. • By signing this Application I hereby (a) adopt and establish my IRA with IRA Services Trust Company, or its successors, as Custodian, (b) understand that the IRA Custodial Account Agreement and this Application comprise my
entire contractual agreement with IRA Services Trust Company, (c) confirm that I have received, read and agree to the terms and conditions contained in the Individual Retirement Custodial Account Agreement for the type of account I selected in Part C of this Application, (d) confirm that I have received, read and agree to the terms and conditions of the appropriate financial disclosure statement and Publication 590, (e) acknowledge receipt of the fee schedule referenced in Part C of this Application, (f) confirm that I have received a copy of IRA Services Trust Company's privacy notice, (g) acknowledge receipt of a current prospectus of the asset(s) named in the Investment Authorization Form which is a part of this Application and (h) understand that IRA Services will handle the daily administration of the account.
• If this Application is to transfer to IRA Services Trust Company the assets of an existing IRA or other retirement account, I understand that the appointment of IRA Services Trust Company as successor Custodian will be effective upon receipt of all the Plan assets. Further, I understand that IRA Services Trust Company, Custodian expressly does not assume or incur any liability by reason of or have a duty or responsibility to inquire into or take action with respect to any acts performed or omitted to be performed by the current Custodian/Trustee. I understand that this transfer may take six weeks or longer.
I declare under penalty of perjury that the foregoing is true and correct, including my social security number.
Participant Signature: ________________________________ Date: ______ / ______ / ______
Spouse Signature*: __________________________________ Date: ______ / ______ / ______
*Only required in community or marital property states, if anyone other than the spouse is named as primary beneficiary. I acknowledge that I am the spouse of the above-named accountholder and do hereby give them any interest that I have in the funds or property in this account and consent to the beneficiary designation(s) indicated above. I assume full responsibility for any adverse consequences that may result. No tax or legal advice was given to me by the Custodian, or its agents or representatives.
FOR CUSTODIAL USE ONLY IRA AGENT REP EST ACC PREP
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INSTRUCTIONS FOR COMPLETING THE NEW ACCOUNT APPLICATION
Part A. PARTICIPANT INFORMATION: Enter your name, address, birth date, social security number, telephone number(s) and email (if available). Your application cannot be processed without all of this information.
Part B. PHOTO ID: Complete this section with the information contained on your CURRENT government issued photo ID (Driver’s License, Passport, etc). In addition, you MUST ATTACH A LEGIBLE COPY OF THE PHOTO ID to this application. This requirement is part of the government’s fight against terrorism and money laundering activities required under the US Patriot Act and other Federal regulations. These laws and regulations, require that financial institutions obtain, verify, and record certain identifying information from an individual seeking to open a new account. We are required to obtain and verify name, address, social security number and other information that will allow us to identify you. After your application has been received, an IRA Services’ representative may contact you to confirm the information provided.
Part C. ESTABLISHING YOUR ACCOUNT DESIGNATING ACCOUNT TYPE: Check the appropriate box next to the type of account you wish to open.
⇒ If you are opening a Traditional or Roth IRA and it is a beneficial account where you are the beneficiary, you must complete the “Supplemental Account Information” form and attach it to your application.
⇒ If you are opening a SEP, please attach a copy of the plan document (or IRS Form 5305-SEP).
⇒ If you are opening a SIMPLE IRA, please attach a copy of the plan document (or IRS Form 5304-SIMPLE). Be sure to include a check for the establishment and annual account fees with your application. See the Fee Schedule for the exact amounts of these fees. If there is no fee check, fees will be deducted from your investment check and may prevent your investment from being completed. Please note that a minimum cash balance is required. FUNDING THE ACCOUNT:
⇒ If you are rolling over a distribution from a previous plan, mark the appropriate check box and enter the amount of the rollover check you are including and the name of the prior custodian or plan.
⇒ If you are transferring funds from a prior custodian, mark the check box and complete a “Transfer Authorization” form and attach it to this application with a copy of the most recent statement.
⇒ If you are making a contribution, mark the check box and indicate the year for which the deposit is being made and the amount of the contribution (between January 1 and April 15 of each year, you may make a prior year contribution if you have not already done so. You are responsible to ensure that contributions do not exceed the limits for the tax year.
⇒ If your employer is making an employer contribution on your behalf, mark the check box and enter the amount of the employer contribution. The check must be made out to IRA Services Trust Company and drawn on the employer’s account.
Part D. DESIGNATION OF YOUR BENEFICIARY: Attach one or more of our “Beneficiary Designation” forms to this application for your primary and secondary beneficiaries. Be sure to date and sign each form. If you do not name your spouse as primary beneficiary and you reside in a community or marital property state, then your spouse must also sign and date these beneficiary forms. We must have original signatures.
Part E. MAKING YOUR INVESTMENT: If you wish to make an investment immediately, complete and attach an “Investment Authorization” form
detailing separately each investment you want to make. Be sure to also attach all documents required by the investment provider. Part F. ACKNOWLEDGEMENT AND SIGNATURE: Read the acknowledgement section carefully to understand important rights, responsibilities,
obligations and information about this account. Finally, complete the application by signing and dating the document. If you do not name your spouse as primary beneficiary and you reside in a community or marital property state, then your spouse must also sign and date the application. We must have original signatures.
Your application may not be processed until the Account Application, photo ID and fees are received. MAILING ADDRESS: Regular Mail IRA Services PO Box 7080, San Carlos CA 94070
Overnight Mail IRA Services 1160 Industrial Rd, Ste 1, San Carlos CA 94070
Telephone: (800) 248-8447 Facsimile: (650) 591-2168
The retirement plan you are establishing is self-directed and you are solely responsible for the success or failure of the investments.
Not FDIC Insured Non-deposit investments are not insured by the FDIC (Stocks, bonds, mutual funds, notes, real estate, partnerships, LLCs, etc.)
Investments are not deposits or other obligations of IRA Services Trust Company and are not guaranteed by IRA Services. Non-deposit investments are subject to investment risk, including possible loss of principal invested.
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BENEFICIARY DESIGNATION
If you wish to name more than two primary or two secondary beneficiaries, please use additional forms and be sure to sign (including spouse, if community property state) and date each page. When received, we will update your file and mail you a confirmation.
IF THIS IS A CHANGE TO A PRIOR DESIGNATION, ALL PRIOR PRIMARY AND SECONDARY BENEFICIARY DESIGNATIONS WILL BE REPLACED WITH THIS DESIGNATION.
Return by mail: PO Box 7080, San Carlos, CA 94070-7080 | fax: 650-591-2168 | e-mail: [email protected] For inquiries, call: 800-248-8447 or visit www.IRAServices.com
A. PARTICIPANT IDENTIFICATION FULL NAME PHONE NO. ACCOUNT NUMBER
_______________________________________________________ ____________________________ __________________________
B. BENEFICIARY AUTHORIZATION I authorize IRA Services, to replace all prior Beneficiary designations on my account with the following designations:
C. PRIMARY BENEFICIARIES Please attach additional pages of this form if necessary 1ST Primary Beneficiary: BENEFICIARY NAME
RELATIONSHIP
BENEFICIARY ADDRESS PERCENT SHARE (PRIMARY BENEFICIARIES MUST TOTAL 100%)
% BENEFICIARY CITY BENEFICIARY STATE BENEFICIARY ZIP
BENEFICIARY SOCIAL SECURITY NUMBER
BENEFICIARY BIRTH DATE BENEFICIARY TELEPHONE NUMBER
2ND Primary Beneficiary: BENEFICIARY NAME
RELATIONSHIP
BENEFICIARY ADDRESS PERCENT SHARE (PRIMARY BENEFICIARIES MUST TOTAL 100%)
% BENEFICIARY CITY BENEFICIARY STATE BENEFICIARY ZIP
BENEFICIARY SOCIAL SECURITY NUMBER
BENEFICIARY BIRTH DATE BENEFICIARY TELEPHONE NUMBER
D. SECONDARY BENEFICIARIES Will be paid only if all the primary beneficiaries pre-decease the account holder 1ST Secondary Beneficiary: BENEFICIARY NAME
RELATIONSHIP
BENEFICIARY ADDRESS PERCENT SHARE (SECONDARY BENEFICIARIES MUST TOTAL 100%)
% BENEFICIARY CITY BENEFICIARY STATE BENEFICIARY ZIP
BENEFICIARY SOCIAL SECURITY NUMBER
BENEFICIARY BIRTH DATE BENEFICIARY TELEPHONE NUMBER
2ND Secondary Beneficiary: BENEFICIARY NAME
RELATIONSHIP
BENEFICIARY ADDRESS PERCENT SHARE (SECONDARY BENEFICIARIES MUST TOTAL 100%)
% BENEFICIARY CITY BENEFICIARY STATE BENEFICIARY ZIP
BENEFICIARY SOCIAL SECURITY NUMBER
BENEFICIARY BIRTH DATE BENEFICIARY TELEPHONE NUMBER
E. SIGNATURE Participant Signature: ________________________________________________________________________ Date: _______ / _______ / _______
If community or marital property state and spouse is not the primary beneficiary, spouse MUST sign below and agree as follows:
I acknowledge that I am the spouse of the above-named account holder and do hereby give them any interest that I have in the funds or property in this account and consent to the beneficiary designation(s) provided. I assume full responsibility for any adverse consequences that may result. No tax or legal advice was given to me by the Custodian, or its agents or representatives.
Spouse Signature: ___________________________________________________________________________ Date: _______ / _______ / _______
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TRANSFER AUTHORIZATION
A transfer occurs when you authorize your current IRA custodian/trustee to transfer assets from your existing account to your IRA Services account. You may only transfer cash and acceptable assets to your IRA Services account. Therefore, any non‐acceptable assets at your existing custodian/trustee must be liquidated and delivered in cash.
This form authorizes a direct transfer of cash and acceptable assets from your current custodian/trustee to IRA Services Trust Company for deposit into your IRA Services account.
Mail ORIGINAL form with a copy of your most recent statement to: PO Box 7080, San Carlos CA 94070 | Overnight Mail: 1160 Industrial Rd, Ste 1, San Carlos CA 94070 For inquiries, call: 800‐248‐8447 or visit www.IRAServices.com
A. PARTICIPANT IDENTIFICATION FULL NAME PHONE NO. SSN
____________________________________ _________________________ ____________________
B. ACCOUNT TO TRANSFER DO NOT complete this form if: You are intending to transfer a 401k, 457, 403b, governmental or other tax‐exempt employer/organization retirement plan (i.e. Profit Sharing Plans, Defined
Benefit Plans, etc.) Movement of assets from these types of plans cannot be processed as a TRANSFER. You MUST contact your Plan Administrator to initiate a ROLLOVER of these types of plans.
Account Type (check one):
+ Traditional IRA + Roth IRA + SEP IRA + SIMPLE IRA + Coverdell Education Savings Account + Other: _______________________________________
Account No: ___________________________________________________________________
Custodian Name: ___________________________________________________________________
Custodian Address: ___________________________________________________________________
Contact Name: ___________________________________________________________________
Contact Phone No.: Contact Fax No.: ___________________________________________________________________
C. CASH/ASSETS TO TRANSFER You MUST submit a copy of your most recent statement from the above listed Custodian. Failure to submit a statement with this form WILL result in processing delays. If you are a first‐time investor with IRA Services, it is recommended that you transfer at least $550 more than your intended investment amount so there are sufficient funds to cover the amount of your investment, the investment purchase fees and the $300 minimum balance requirement.
+ Transfer ALL available cash By checking this option, I understand that my account with the above listed Custodian must be liquidated into a cash position prior to submitting this request to IRA Services or delays may occur.
+ Transfer EXACTLY: $ _____________________ By checking this option, I understand that there must be sufficient cash available in my account with the above listed Custodian prior to submitting this request to IRA Services or delays may occur.
+ Transfer ALL assets in kind (including cash)
+ Transfer ONLY the following assets in kind (please attach a separate page if necessary):
Asset name: _________________________________________ No. of shares: __________ Value: $________________
Asset name: _________________________________________ No. of shares: __________ Value: $________________
Asset name: _________________________________________ No. of shares: __________ Value: $________________
Asset name: _________________________________________ No. of shares: __________ Value: $________________
D. DELIVERY INSTRUCTIONS FOR CUSTODIAN Please choose from the options below on how you would like your Custodian to deliver your cash/assets to IRA Services. If no option is selected, your Custodian will choose for you.
+ Mail (For checks & in‐kind documents) Send checks and “in‐kind” transfer documents (if applicable) to: IRA Services, PO Box 7080, San Carlos CA 94070.
Make checks payable to “IRA Services Trust Company, Custodian”. Please reference the Participant’s name and our account number on the check. For overnight deliveries: IRA Services, 1160 Industrial Rd Suite 1, San Carlos CA 94070
+ Wire (Incoming Wire Fee applies) Institution Name: Fremont Bank / Beneficiary Acct Name: IRA Services / Routing Transit No. (ABA): 121107882 / Beneficiary Acct No.: 19902328
Do not send cash via ACH For Further Credit: “FBO Participant Name & Our Account Number”
+ DTC (For publicly traded assets only such as stocks, bonds, mutual funds, etc.) Do not send cash via DTC Firm: UVest Financial Services / DTC No.: 0443 / Account Title: IRA Services Trust Company, Custodian / Account No.: 3R9710532
E. PARTICIPANT AUTHORIZATION By signing below, I acknowledge that the appointment of IRA Services Trust Company as custodian will become effective upon receipt of the assets from the prior custodian/trustee. I further acknowledge that IRA Services Trust Company assumes no liability for the action or inaction of the prior custodian/trustee as to the proper and timely transfer of funds.
Signature of IRA Participant: ________________________________________________ Date : _____ / _____ / _____
IRA SERVICES TRUST COMPANY’S ACCEPTANCE This section is for IRA Services to complete. NOT to be completed by Participant.
IRA Services Trust Company accepts its appointment as Custodian. Medallion Signature Guarantee:
Authorized IRA Services Signature: _______________________________
(Tax ID: 26‐2627205)
Date: _______________________________
IRA SERVICES TRUST COMPANY ACCOUNT INFORMATION ACCOUNT NUMBER ACCOUNT TYPE
+ Please check this box if you would like your request EXPEDITED Expedite fee applies. Please see our FEE SCHEDULE & FINANCIAL DISCLOSURE. Non‐expedited processing time to forward request to Custodian is 2‐3 business days
+ Please check this box if you would like IRA Services to forward this request to your Custodian by OVERNIGHT DELIVERY (Overnight delivery fee + cost* applies)
* Charge cost to FedEx or UPS (circle one) account #: _________________________ (If no account # is provided, it will be charged to your IRA account.)
Please be sure to provide the Overnight Delivery address on the left or processing delays will occur. Default delivery method is USPS Priority Mail if this option is not chosen.
V20110211
If transferring assets in‐kind, please provide on a separate page the most current contact information of your investment sponsors
(company name, address, contact name, phone number, fax number & email address).
We cannot complete your request without this.
INVESTMENT AUTHORIZATION
This form must be used to authorize the purchase of any investment.
Return by mail: PO Box 7080, San Carlos, CA 94070 | fax: 650‐591‐2168 | e‐mail: [email protected] For inquiries, call: 800‐248‐8447 or visit www.IRAServices.com
A. PARTICIPANT IDENTIFICATION FULL NAME PHONE NO. ACCOUNT NUMBER
________________________________________________________ _____________________________ __________________________
B. ACKNOWLEDGMENT & AUTHORIZATION
I hereby acknowledge that I am solely responsible for the investment instructions I am making. I hold harmless, protect and indemnify the Custodian and Administrator from and against any and all liabilities, losses, damages, expenses and charges that the Custodian and Administrator may sustain or might sustain resulting directly or indirectly from my investment. I further acknowledge that I am solely responsible for the success or failure of this investment. I hereby authorize the purchase of the asset listed below for my IRA Services account.
C. INVESTMENT INSTRUCTIONS
Asset Name and Asset Type (i.e. Promissory Note, LLC, Limited Partnership, private REIT, private common/preferred stock, etc.)
_________________________________________________________________________________________________________________________
Contact Information
Sponsor/Managing Partner Name
_______________________________________
_______________________________________
Address
__________________________________________________
__________________________________________________
Telephone
___________________________
E‐mail
___________________________________
Amount to Purchase (check one) Please note we will hold back funds to complete the $300 minimum required balance and to cover any investment‐related fees before sending your requested amount. If there are insufficient funds to cover the minimum balance and/or fees, your request will be put on hold until sufficient funds are available.
+ Invest exactly $_________________ + Invest all available cash, less minimum required balance (Please specify amount of cash required in custodial cash account before purchase is made: $_________________) + Total shares/units to purchase: ______________
When to Purchase (check one)
+ Purchase as soon as possible (default option) + Purchase each month OR quarter (circle one) beginning on or after (mm/dd/yȅȅy): ______ / ______ / ______
D. IN‐KIND INVESTMENT INSTRUCTIONS Complete this section only if you are making an investment “in‐kind” of assets into an IRA LLC
Name of IRA LLC: ______________________________________________________________ Assets to invest in‐kind into the IRA LLC: (invest all shares unless otherwise noted)
E. DOCUMENT REQUIREMENTS Incomplete documentation may result in the inability of the custodian/administrator to complete your request in a timely manner.
There may be several documents required to complete your investment transaction. The investment package you send to us must contain all of the required documentation in order to be processed. Please refer to the INVESTMENT DOCUMENT REQUIREMENTS document. Please make sure that all forms are completed correctly. Administrator will complete the documentation including registration and Tax ID.
Assets are to be registered as follows:
IRA Services Trust Company, Custodian FBO [your name] [account no.]
Tax ID: 26‐2627205
F. FUNDING INSTRUCTIONS Please indicate how funds from your account are to be sent for purchase of the asset listed above
Send a check using the following service:
+ Regular Mail
+ Overnight Mail (overnight delivery fee + cost* applies)
* Charge cost to FedEx or UPS (circle one) account #: _________________________________ If no account # is provided, it will be charged to your account
Payee Name & Address:
Payee Name: __________________________________________________________
Address: ______________________________________________________________
City/State/Zip: _________________________________________________________
If sending to a bank, please reference bank account number and “c/o or Attn to”:
______________________________________________________________________
Send a wire: (wire transfer fee applies)
Bank Name: ___________________________________________________________
Bank Address: __________________________________________________________
Telephone Number: _____________________________________________________
ABA (wire routing number): _______________________________________________
Account Name: _________________________________________________________
Account Number: _______________________________________________________
Reference: ____________________________________________________________
G. PARTICIPANT SIGNATURE
Participant Signature: ________________________________________________ Date: ________ / ________ / ________
Asset Name
____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________
No. of Shares/Units
__________________ __________________ __________________ __________________
Amount/Value
$_________________ $_________________ $_________________ $_________________
+ Please check this box if this is an international wire Please provide the domestic/intermediary bank instructions below and international bank instructions on a separate piece of paper.
CUSTODIAL USE ONLY
V20110111
+ Please check this box to EXPEDITE this request (expedite fee applies) You must have sufficient funds in your
account for this request to be expedited and that all required documentation, if applicable, is included with this form
REPRESENTATIVE AUTHORIZATION
You must complete this authorization to allow your representative to review your statements and access your account information.
Return by mail: PO Box 7080, San Carlos, CA 94070 | fax: 650‐591‐2168 | e‐mail: [email protected] For inquiries, call: 800‐248‐8447 or visit www.IRAServices.com
A. PARTICIPANT IDENTIFICATION
FULL NAME PHONE NO. ACCOUNT NUMBER
_______________________________________________________ ____________________________ ___________________________
B. REPRESENTATIVE IDENTIFICATION REPRESENTATIVE NAME FIRM NAME
____________________________________________ _________________________________________
FIRM STREET ADDRESS FIRM CITY/STATE/ZIP
_______________________________________________ ______________________________________ FIRM TELEPHONE FIRM FAX REPRESENTATIVE E‐MAIL __________________________________ __________________________________ ___________________________________________
C. REQUEST FOR FIRST CONTACT
+ Please check this box if you would like your Representative to be contacted first should any questions or concerns arise regarding your account.
D. AUTHORIZATION
I hereby authorize IRA Services Trust Company as Custodian and IRA Services Inc. as Administrator of my account to allowthe aforementioned Representative to:
Access my account information, including copies of my account statements, tax filings and online account information.
Contact IRA Services Trust Company to discuss my account holdings and activity.
E. SIGNATURE
_______________________________________
Signature of Participant
_______ /_______ / _______
Date
FOR CUSTODIAL USE ONLY
V20111011
INTERNET ACCESS REQUEST
You must complete this form to establish Internet access to your account(s) with IRA Services. You will receive an e‐mail from [email protected] with your temporary password. Please add this e‐mail address to your Spam filter list to ensure you receive your password.
Your login name will be your account number (including the 3‐letter prefix).
Return by mail: PO Box 7080, San Carlos, CA 94070 | fax: 650‐591‐2168 | e‐mail: [email protected] For inquiries, call: 800‐248‐8447 or visit www.IRAServices.com
A. PARTICIPANT IDENTIFICATION FULL NAME PHONE NO. ACCOUNT NUMBER
_______________________________________________________ ____________________________ ___________________________
B. E‐MAIL ADDRESS (Required)
PLEASE PROVIDE YOUR EMAIL ADDRESS
______________________________________________________________________________
C. INTERNET ACCESS ACCEPTANCE I hereby request Internet access to ALL my account(s) (both current and future) under the following social security number:
_________ ‐ ______ ‐ ________
By signing below, I acknowledge, on behalf of myself and all users authorized by me (individually and collectively referred to herein as "I"), that:
By using IRA Services' Internet services I agree to the terms stated in this Agreement and the Account Access Terms and Conditions of Use set
forth on the Internet web site.
I will be issued a unique User ID and an initial password. For security purposes I understand that I must change my initial password to a
password of my own choosing upon accessing my account(s) for the first time.
The password that I will be given to gain access to IRA Services' internet services should be kept confidential, and that IRA Services is not
responsible for any breach of security caused by my failure to maintain the confidentiality of my password.
I acknowledge and accept that IRA Services has no obligation to confirm the identity of any person using my User ID and password.
If I disclose my User ID and password to a third party, I hereby indemnify and hold IRA Services harmless for any action or instruction of such
third party in my name.
If I intend to revoke my authorization of such third party, I will immediately change my password.
If I believe my User ID and password have been lost or stolen or used without my permission, I will contact IRA Services security operations at
[email protected] or call 1‐800‐248‐8447 during regular business hours.
I understand IRA Services expressly discourages me from sending personal, business, financial or account information via Internet e‐mail.
If I choose to send Internet e‐mail messages to IRA Services that contain confidential information, I understand that I do so entirely at my own
risk, and that IRA Services will not be responsible for any loss or damages that I may incur if I communicate such confidential information by
Internet e‐mail.
I hereby agree that IRA Services is not responsible for any direct, indirect, special, incidental or consequential damages arising in any way out
of my use of IRA Services' Internet services, and that this agreement shall be governed in accordance with the laws of the state of California.
I agree to hold IRA Services harmless from all losses, liability, demands, judgments, claims and expenses from my use of the website and the
Internet services IRA Services provides. I provide the indemnification without regard as to whether your claim is against me or my authorized
representative.
D. PARTICIPANT SIGNATURE _____________________________________________________ _______ / _______ / _______ Signature of Participant Date
V20110111
FEE SCHEDULE & FINANCIAL DISCLOSURE
FEE SCHEDULE Effective January 1, 2011
Fee Description: Amount of Fee Establishment Fee (Must accompany your application1
) ...........................................................................$55.00 (One Time Fee)
Annual Account Fee (Must accompany your application1
from your account the first day of each subsequent calendar year. This fee is and then is automatically deducted ..........................................$65.00
not
Quarterly Asset Fees
pro-rated.)
2
Brokerage Account Asset (Account within IRA used to trade stock, bonds, etc.) ..........................................$6.00 per account (Automatically deducted from your account at the time of purchase and the first day of each calendar quarter)
Tier 1 Assets (Assets publicly available which may be traded on a financial exchange & precious metals) ...................$6.00 per asset Tier 2 Assets (Assets such as private placements, non-public partnerships, notes, deeds of trust etc.) ....................$10.00 per asset
Tier 3 Assets (Assets such as real property)........................................................................................$16.00 per asset Transaction Fees (Automatically deducted from your account at the time of the transaction)
Cash Disbursement via check.................................................................................................$10.00 per check Cash Disbursement via ACH (periodic only) ................................................................................. $ 5.00 per ACH Purchase of Tier 1 Assets .......................................................................................................$20.00 per asset Purchase of Tier 2 Assets .......................................................................................................$35.00 per asset Liquidation/Sale of Tier 1 or 2 Assets ....................................................................................$25.00 per asset Re-Registration of Tier 1 or 2 Assets (Including Transfers In3
Purchase / Transfer / Sale of Tier 3 Assets ............................................................................$75.00 per asset and Out)...............................................$35.00 per asset
Roth Conversion / Recharacterization ..................................................................................$50.00 Precious Metals Asset Storage Fee (Charged upon initial purchase and annually thereafter) ................... $100.00 minimum4
Termination Fee ....................................................................................................................... $100.00 (In addition to any Transaction Fees that apply)
Other Service Fees Non-Standard Administrative Activity ........... $35.00 Invoice for Fees ...........................$15.00 Wire Transfer In ............................................. $15.00 Duplicate Statement ...................$10.00 Wire Transfer Out-International .................... $35.00 Overnight Delivery ......................$15.00 plus cost Wire Transfer Out-Domestic .......................... $25.00 Precious Metals Shipping5
Stop Payment/Returned Check...................... $20.00 Research .....................................$75.00 per hour ..........$15.00 plus cost
Corrected 1099R/5498 ................................... $15.00 Expedited Processing ..................$50.00
Any other services provided, that are not listed above, will be charged to the account. Contact IRA Services for the exact charge for these other services. Fee Invoicing: Fees are automatically deducted from your account at the time they are charged. If you do not have sufficient funds to pay these fees an invoice may be included with your next quarterly statement. If an invoice is issued, there will be a charge applied to that invoice, as noted above. You can avoid this invoicing fee by maintaining the minimum cash balance, as noted below, in your account. The minimum balance is a part of your account and must be a contribution, rollover, transfer from a qualified plan or earnings within your account.
1 Failure to pay the Establishment & Annual Account fees with your application may delay the processing of your account setup and initial investment. 2 IRA Services reserves the right to categorize any particular asset into one of the asset tiers shown or created in the future. Contact IRA Services for the categorization of
any asset. Asset Fees are not charged to Coverdell Educational Savings Accounts. 3 Assignments by a prior custodian may require a re-registration by IRA Services and the imposition of this fee. 4 Depository Storage Fees will be billed at the rate of $1 per $1,000 of Assets held at depository, minimum of $100.00 per year, and are not prorated. 5 Shipping fees may be charged on both inbound and outbound shipments from the Depository.
V20110101
FINANCIAL DISCLOSURE
The financial performance of your account is not guaranteed and cannot reasonably be projected over a period of years. Additionally, IRA Services Trust Company cannot supply any financial data projecting the financial performance of your investments. The value of your account will depend on the investment results of the account’s assets, less fees and expenses charged to your account and custodial fees which are charged to your account, if not paid directly by you.
MINIMUM CASH BALANCE The account must, at all times, maintain a minimum cash balance in the custodial cash account of $300. This cash balance is an asset of your account and must be part of a contribution, rollover, transfer from another qualified plan or earnings within your account. Failure to maintain this balance may result in the distribution of the account to the participant.
CUSTODIAL CASH DISCLOSURE
All cash for which the account holder has not provided investment instructions will be deposited into a pooled custodial deposit account or accounts with one or more third party FDIC-insured financial institutions selected by IRA Services Trust Company or its affiliates. The custodial cash account will pay interest on these account holder funds based on the rate paid by one financial institution selected by IRA Services Trust Company on similar accounts at that institution. IRA Services Trust Company or its affiliates may enter into a sub-accounting agreement with the selected financial organizations, in which IRA Services Trust Company or its affiliates will maintain all records pertaining to the account holder's share of the pooled custodial accounts and prepare withdrawals of account holder's funds from such pooled custodial accounts for distributions, investments, fees and other disbursements as directed or agreed to by the account holder. The account holder hereby indemnifies and agrees to hold such financial organization(s) harmless from following the directions received from IRA Services Trust Company or its affiliates on the account holder's behalf. IRA Services Trust Company or its affiliates may receive a sub-accounting fee (at no cost to the account holder) from the financial organizations.
Page 2 of 2
FEE SCHEDULE & FINANCIAL DISCLOSURE
V20110101
PRIVACY NOTICE
YOUR PRIVACY IS IMPORTANT TO US
You provide important information about yourself to a variety of businesses and organizations. The same is true when you do business with IRA Services Trust Company. You are asked to provide us with certain personal information that helps us give you better service and complete your transactions more effectively. We work diligently to safeguard the information you give to us. In fact, we have developed the following policies to ensure your confidentiality and to maintain your confidence in our institution. These policies detail the strict standards we have in place. For this reason, we ask you to please read the following information carefully. In it, we will tell you the sources for nonpublic personal information we collect on our customers, and what measures we take to secure that information.
DEFINITIONS
We, our, and us, when used in this notice, mean IRA Services Trust Company. The words you and your mean account customers who have continuing relationships with us in self-directed IRA accounts where we act as custodian or trustee. Nonpublic personal information means information about you that we collect in connection with providing a financial product or service to you. Nonpublic personal information does not include information that is available from public sources, such as telephone directories or government records. An affiliate is a company we own or control, a company that owns or controls us, or a company that is owned or controlled by the same company that owns or controls us. Ownership does not mean complete ownership, but means owning enough to have control. A nonaffiliated third party is a company that is not an affiliate of ours.
INFORMATION THAT WE COLLECT ABOUT YOU
We collect nonpublic personal information about you from the following sources:
Information we receive directly from you on applications and other forms
Information about your transactions with us
Information about your transactions with nonaffiliated third parties
Information from consumer reporting agencies
INFORMATION WE DISCLOSE ABOUT YOU 3
It is our policy not to disclose any nonpublic personal information about customers to anyone, except as required by law. Naturally, in the course of providing you with products or services that you have requested or already have with us, when necessary we disclose customer information required by companies who work for us, such as check printing or data processing companies.
THE CONFIDENTIALITY, SECURITY AND INTEGRITY OF YOUR NONPUBLIC PERSONAL INFORMATION
We limit access to nonpublic personal information to those employees who need to know that information to provide products or services to you. We maintain physical, electronic, and procedural safeguards that comply with Federal standards to guard your nonpublic personal information.
NON-PUBLIC PERSONAL INFORMATION AND FORMER CUSTOMERS
It is our policy not to disclose any non-public personal information about former customers to anyone, except as permitted by law.
V20110111
INTERNET ACCESS REQUEST TERMS & CONDITIONS
This statement of Internet Access Terms and Conditions contains the terms that govern your use of the IRA Services online site and services. By using the website iraservices.com you explicitly agree to be bound by these terms and conditions. Purpose of Site - Our purpose in providing this Internet website is to provide you, our client, with fast and efficient customer service support that is convenient for you to use. We provide this information for your use in a secure environment using several security methods to ensure as secure a site as possible while providing you with access. Security of Information - IRA Services has used the following security methods to make the site as secure as possible;
Your Unique ID - You have been provided with a unique identification code with which to login into the website. The ID is also your account number and should not be provided to other parties or persons not authorized by you to have access to this site.
Your Password - You will be provided with a unique randomly generated password that will give you initial access to your eligible accounts. When you log on for the first time, you will be required to change your password. You will also be required to establish three personal questions and answers that you must answer should you lose your password and need to be issued a new password. IRA Services staff DO NOT know your questions, answers nor password.
Security Techniques - In addition to the items above, security is further enhanced by the use of the industry standard SSL (Secure Sockets Layer) security method that encrypts your account information when it is transmitted over the Internet. It uses the highest degree of Internet security presently available.
Access to your Accounts -You must authorize IRA Services to provide access to your eligible accounts by completing the Internet Access Request (see Forms Download area) and sending it to IRA Services as described on the form. You may remove your authorization by providing written instructions to that effect at IRA Services, PO Box 7080, San Carlos, CA 94070 or by email to [email protected]. You may view your account information, including balances, transactions, tax information and investor profile at the website: www.IRAServices.com. You will generally be able to access your account information seven days a week, twenty-four hours per day. There may be times when the service is not available due to system maintenance or circumstances beyond our control. If you need information about your account at these times, call our customer service center at 1-800-248-8447 during regular business hours. Liability - IRA Services Trust Company or IRA Services, Inc., including their directors, officers, employees, agents and other related persons) are not liable for any losses or damages arising from your use of the website. This includes those instances where IRA Services Trust Company/IRA Services Inc. have exercised reasonable care, in instances where they do not have direct control or any situation which causes the website to be unavailable for any extended period of time. Further, the losses or damages may arise without limitation in connection with mechanical equipment failures, electronic equipment failures, communication systems interruptions/failures, data processing failures, unauthorized access to any facility including the Internet, operator errors, thefts, natural disasters, labor problems, war, military or governmental action or inaction, electronic systems not controlled by IRA Services (such as the Internet or telephone lines). The use by you of electronic systems not controlled by IRA Services is solely at the user's risk/liability. IRA Services and First Regional Bank will not be responsible for the security of and the resulting losses from the transmission of data on any systems not controlled by them. Indemnification - Except to the extent that we are liable under the terms of this agreement or any other agreement between you and IRA Services or any
law applicable, you agree to hold us, our directors, officers, employees, agents and other related persons harmless from all losses, liability, demands, judgments, claims and expenses from your use of the website and the Internet services we provide. You provide the indemnification without regard as to whether our claim is against you or your authorized representative.
Use of Third Parties - Except as provided in applicable law, neither we nor our service providers or other agents and related persons shall be liable for any loss or liability from the failure of your equipment, your software or your access to the Internet provided by your Internet access provider.
IN NO EVENT SHALL WE (IRA Services Trust Company or IRA Services, Inc.) HAVE ANY LIABILITY FOR ANY SPECIAL, PUNITIVE, INDIRECT OR CONSEQUENTIAL LOSS OR DAMAGE REGARDLESS AS TO WHETHER THE CLAIM FOR SUCH LOSS OR DAMAGE IS BASED ON ANY CONTRACT OR TORT THAT WE HAD KNOWLEDGE OF OR SHOULD HAVE HAD KNOWLEDGE OF OR WHETHER WE SHOULD HAVE KNOWN ABOUT THE POSSIBILITY OF SUCH LOSSES OR DAMAGES IN ADVANCE. Technical Support - IRA Services will provide technical support during the hours of 9:00 AM to 4:00 PM Pacific time Monday through Friday excluding holidays. You may call us at 1-650-593-2221 or you may send an email to [email protected]. Other Terms
Termination - IRA Services may terminate this agreement and/or your access to the IRA Services website in whole or in part at any time, unless otherwise required by law.
Changes - We may change the terms of the Agreement from time to time and at any time. Such changes will be updated to this Agreement on the website within thirty (30) days of any change.
Notifications - Unless required by applicable law, any notice we are required to provide to you in writing, may be provided to you, at our discretion, electronically to your current email address in our records.
Governing Law - This agreement shall be governed by the laws of the State of California.
Entire Agreement - This agreement, Internet Access Request, and any other disclosures or documents that we provide to you from time to time constitute the entire agreement and is the only agreement between you and IRA Services regarding this service
© 2011 IRA Services V20030815
V20110111
REPRESENTATIVE INTERNET ACCESS REQUEST
You must complete this form to establish Internet access to your clients’ account(s) with IRA Services.
Return by mail: PO Box 7080, San Carlos, CA 94070 | fax: 650‐591‐2168 | e‐mail: [email protected] For inquiries, call: 800‐248‐8447 or visit www.IRAServices.com
A. REPRESENTATIVE IDENTIFICATION
FULL NAME PHONE NO.
_______________________________________________________ ____________________________ FIRM NAME ADDRESS CITY/STATE/ZIP
________________________________ ________________________________ __________________
B. E‐MAIL ADDRESS (Required)
PLEASE PROVIDE YOUR EMAIL ADDRESS
______________________________________________________________________________
C. INTERNET ACCESS ACCEPTANCE I hereby request Internet access to ALL account(s) (both current and future) whose account holders have authorized me to have access to their accounts for review purposes.
By signing below, I acknowledge, on behalf of myself and all users authorized by me (individually and collectively referred to herein as "I"), that:
By using IRA Services' Internet services I agree to the terms stated in this Agreement and the Account Access Terms and Conditions of Use set forth on
the Internet web site.
I will be issued a unique User ID and an initial password. For security purposes I understand that I must change my initial password to a password of
my own choosing upon accessing my account(s) for the first time.
The password that I will be given to gain access to IRA Services' Internet services should be kept confidential, and that IRA Services is not responsible
for any breach of security caused by my failure to maintain the confidentiality of my password.
I acknowledge and accept that IRA Services has no obligation to confirm the identity of any person using my User ID and password.
If I disclose my User ID and password to a third party, I hereby indemnify and hold IRA Services harmless for any action or instruction of such third
party in my name.
If I intend to revoke my authorization of such third party, I will immediately change my password.
If I believe my User ID and password have been lost or stolen or used without my permission, I will contact IRA Services security operations at
[email protected] or call 1‐800‐248‐8447 during regular business hours.
I understand IRA Services expressly discourages me from sending personal, business, financial or account information via Internet e‐mail.
If I choose to send Internet e‐mail messages to IRA Services that contain confidential information, I understand that I do so entirely at my own risk,
and that IRA Services will not be responsible for any loss or damages that I may incur if I communicate such confidential information by Internet e‐
mail.
I hereby agree that IRA Services is not responsible for any direct, indirect, special, incidental or consequential damages to me or my clients arising in
any way out of my use of IRA Services' Internet services, and that this agreement shall be governed in accordance with the laws of the state of
California.
I agree to hold IRA Services harmless from all losses, liability, demands, judgments, claims and expenses from your use of the website and the Internet
services we provide. You provide the indemnification without regard as to whether our claim is against you or your authorizing client.
D. REPRESENTATIVE SIGNATURE _____________________________________________________ _______ / _______ / _______ Signature of Participant Date
CUSTODIAL USE ONLY ID ASSIGNED DATE ASSIGNED
V20110111
