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IRA and Roth IRA Withdrawal and Tax Withholding Election Form State Income Tax Withholding6 You must complete this section for Traditional IRA or SEP-IRA …
IRA and Roth IRA Withdrawal and Tax Withholding Election Form The attached traditional IRA and Roth IRA Withdrawal and Tax Withholding Election Form may be used to request a withdrawal from your traditional IRA or Roth IRA or SEP-IRA and/or provide instructions regarding withholding of Federal and State Income Tax. For Keogh Plans, please call 1-800-695-5911.* This form may not be used to transfer funds to another institution. If you wish to transfer your IRA to another institution, please obtain a transfer form from that institution. This form may not be used for distributions due to death. In this case, you must complete an IRA and Roth IRA Withdrawal and Tax Election Form for Beneficiaries.

Please review the important information below before you complete your form. Withholding for Federal and State Income Tax By law, Citibank is required to withhold for Federal and State Income Tax, as applicable, from your traditional IRA and SEP-IRA distributions, including those excludable from gross income, unless you elect not to have withholding apply. Mandatory withholding does not apply for Roth IRAs. If you are a resident of a state that would require state tax withholding we are also required to withhold state tax unless your state permits you to opt out of such state tax withholding and you have done so properly. If you receive a payment before age 59 1/2, you may have to pay a 10% premature distribution penalty. For applicable District of Columbia (lump sum withdrawals/distributions only), Iowa, Kansas, Maine, Massachusetts, Nebraska (nonpremature withdrawals/distributions), North Carolina, Oklahoma, Oregon and Vermont residents, we must also withhold a portion of the payments for state income tax purposes if there is withholding for federal income tax purposes. If you are a resident of one of the following states and do not specifically opt out of state withholding, state withholding will be mandatorily applied: Arkansas, California, Georgia (periodic withdrawals/distributions only), Michigan and Mississippi (premature or excess distributions). If you are a resident of one of the following states, state withholding is mandatory, as indicated: Delaware (for payments outside of the U.S. for accounts with a missing or incorrect taxpayer identification number, or TIN) and South Carolina (accounts with a missing or incorrect TIN). If you elect not to have taxes withheld, or if insufficient taxes are withheld, you may be responsible for payment of estimated tax. You may also incur penalties under the estimated tax rules if withholding and estimated tax payments are not sufficient. If you do not provide a U.S. resident address (for example, if you list a P.O. Box), Federal Income Tax must be withheld from your traditional IRA and SEP-IRA distributions. Converting a traditional IRA to a Roth IRA If you want to convert funds from your Citibank traditional IRA to a Citibank Roth IRA, attach a completed Citibank Roth IRA Application Form (or Contribution Form if you already have a Citibank Roth IRA) to a completed Citibank IRA and Roth IRA Withdrawal and Tax Withholding Election Form. If a completed Roth IRA Application Form (or Roth Contribution Form) does not accompany the IRA and Roth IRA Withdrawal and Tax Withholding Election Form, the funds from the traditional IRA will be distributed to you, and you must contribute them to a Roth IRA within sixty (60) days of receipt as a conversion contribution. When completing the attached form, be sure to include the following: • • • • • •

Complete Name and Residential Address Social Security Number Date of Birth Type of Plan (traditional IRA, SEP-IRA or Roth IRA) Type of Withdrawal Account Number(s)

• Tax Withholding Election for Traditional IRA or SEP-IRA Withdrawals (Completing Section 5 & 6 is very important) • Signature and Date Please return the completed form to: C.D.S.I. Retirement Plan Services 100 Citibank Drive San Antonio, TX 78245 Or you may return the form to your nearest Citibank Branch. If you have questions concerning this form or your retirement plan, please contact a Retirement Plan Specialist at 1-800-695-5911.* For Text Telephone (TTY) Service in the U.S., call 1-800-788-6775.

* To ensure quality service, calls are recorded. © 2014 Citibank. Citibank, N.A. Member FDIC. Citibank with Arc Design is a registered service mark of Citigroup Inc. Item RPS036 (Rev. 4/14)

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IRA and Roth IRA Withdrawal and Tax Withholding Election Form 1 Account Owner Information Please print and press firmly. Social Security No._______________________________________ Branch No. ______________ FIMP No. _____________  Check here if new address Name ____________________________________________________________________________________________________________________________________

First Middle Last

Residential Address _______________________________________________________________________________________________________________________

Apt. Number

City _______________________________________________________________________ State ____________ Zip ________________________________________ Date of Birth _____________________________ Home Phone (________) ________________________ Business Phone (________) _________________________ 2 Type of Plan Indicate the type of Plan from which you are taking a withdrawal (select only one)  Traditional IRA

 Roth IRA

 SEP-IRA

 Rollover IRA

3 Type of Withdrawal Please check one  Premature Distribution (before age 59 1/2; may be subject to a 10% IRS tax penalty)  Regular Distribution (after age 59 1/2)  Recharacterization to an IRA

 Permanent Disability  Conversion to Roth IRA  Recharacterization to a Roth IRA

 Recharacterization to a SEP-IRA  Remove Excess Contribution  For Prior Year  For Current Year  To remove earnings attributable

4 Withdrawal Choices  Please check here if scheduled IRA contributions are currently being deducted from your Citibank checking account, and you would like to cancel that schedule. A. One-Time Withdrawals from FDIC-Insured Investment Options 1. Select one:

 Immediate

2. Select one:

 Withdraw my total IRA or Roth IRA Plan balance

 At Maturity

 Future Date (specify): _____________________________________________________________



 Withdraw this amount (specify): _______________ from this IRA or Roth IRA account number (specify): __________________________

B. Periodic Distributions From FDIC-Insured Investment Options 1. Select Payment Schedule:  Monthly  Quarterly  Annually (Your monthly payment schedule will commence approximately one month after the date that Retirement Plan Services receives your request.) 2. Select Withdrawal(s):

 Withdraw this amount (specify): ___________ from this IRA or Roth IRA account number (specify):_____________________



 Withdraw this amount (specify): ___________ from this IRA or Roth IRA account number (specify):_____________________



W  ithdraw Interest Only* from this (these) IRA or Roth IRA account number(s) (specify):______________________________ (*Interest Only refers to the interest earned on your Day to Day Savings, Money Market Account, or CD) ______________

5 Federal Income Tax Withholding You must complete this section for Traditional IRA or SEP-IRA Withdrawals Please review “Withholding for Federal and State Income Tax” on the cover page of this form. • For applicable District of Columbia (lump sum withdrawals/distributions only), Iowa, Kansas, Maine, Massachusetts, Nebraska (non-premature withdrawals/distributions only), North Carolina, Oklahoma, Oregon and Vermont residents, we must also withhold a portion of the payments for state income tax purposes if there is withholding for federal income tax purposes. • If you are a resident of one of the following states and do not specifically opt out of state withholding, state withholding will be mandatorily applied: Arkansas, California, Georgia (periodic withdrawals/distributions only), Michigan or Mississippi (premature or excess distributions). • If you are a resident of one of the following states, state withholding is mandatory, as indicated: Delaware (for payments outside of the U.S. for accounts with a missing or incorrect taxpayer identification number, or TIN) and South Carolina (accounts with a missing or incorrect TIN). a. For Required Minimum Distributions only: (check one:) D  o not withhold Federal Income Tax (applicable only to your Required Minimum Distribution or periodic withdrawal).

 Withhold Federal Income Tax at 10% on my non-periodic withdrawal RMD.

 Withhold Federal Income Tax at 10% on my periodic withdrawal RMD.

b. For unscheduled distributions: (check one:) D  o not withhold Federal Income Tax.

 Withhold Federal Income Tax at the percentage indicated: ____________ % (in whole percentages greater than 10%).

c. Check one:  I revoke all previous federal tax withholding elections and agree to apply the above withholding election to all future distributions from this plan. T  he above federal tax withholding election will apply only to the current distribution. Any previous federal withholding election will remain in effect for all future plan distributions. Item RPS036 (Rev. 4/14) Pkg. 25

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IRA and Roth IRA Withdrawal and Tax Withholding Election Form 6 State Income Tax Withholding You must complete this section for Traditional IRA or SEP-IRA Withdrawals if you reside in one of the following states: AR, CA, DC, GA, IA, KS, MA, MI, ME, MS, NC, NE, OK, OR, or VT. Please review “Withholding for Federal and State Income Tax” on the cover page of this form. If you are a resident of a state that would require state tax withholding we are also required to withhold state tax unless your state permits you to opt out of such state tax withholding and you have done so properly. State law is subject to change and Citibank is not responsible for changes in State laws that occur. I reside in one of the following states that have additional requirements which are outlined below. Please review and circle your state of residence: AR, CA, DC, GA, IA, KS, MA, MI, ME, MS, NC, NE, OK, OR, or VT. • I acknowledge that my state of residence is Arkansas, California, Georgia, Michigan or Mississippi and that if I do not specifically opt out of state withholding, state withholding will apply to my IRA distribution. For Georgia residents, this requirement only applies to periodic payments. For Mississippi residents, this requirement applies to premature or excess distributions. • A  s a resident of one of the following states, I acknowledge state tax withholding is mandatory when I elect to withhold federal tax: District of Columbia, Iowa, Kansas, Maine, Massachusetts, Nebraska, North Carolina, Oklahoma, Oregon or Vermont. For: • District of Columbia, such withholding would apply to lump sum withdrawals/distributions only, • Nebraska, such withholding would apply to non-premature distributions only. • A  s a resident of one of the following states, I acknowledge state tax withholding is mandatory regardless of my federal tax election for Arkansas, California, Georgia (periodic payments only), Michigan or Mississippi unless I specifically opt out by completing, signing and returning a state specific form. a.  I opt to withhold the following amount for state taxes (in whole percentages) ______% See attached form for State Tax Information for IRAs. For mandatory states, if you elect to withhold an amount that is less than the amount required by your state, we will withhold the minimum amount required by your state. In the event that your state raises the minimum tax withholding rate, we will apply minimum tax withholding amount required by your state if it is greater than the amount you elected to withhold. If you move to a new state, the state requirements of your new state will apply, and we will withhold the minimum amount required by that state if it is greater than the amount you elected to withhold. b.  I opt out of state tax withholding. To access a form go to: • R  esidents of Arkansas must submit Form AR-4P to opt out. The form is located at: http://www.state.ar.us/dfa/income_tax/documents/AR4P_2006_ Draft.pdf • Residents of California must submit Form DE-4P to opt out. The form is located at: http://www.edd.ca.gov/pdf_pub_ctr/de4p.pdf • R  esidents of Georgia must submit Form G-4P to opt out. The form is located at: https://etax.dor.ga.gov/inctax/withholding/TSD_Withholding_from_ Pensions_and_Annuities_G4P.pdf • Residents of Michigan must submit Form MI-4P to opt out. The form is located at: http://www.michigan.gov/documents/taxes/4924_365368_7.pdf • Residents of Mississippi must submit Form 89-350-10-2 to opt out. The form is located at: http://www.dor.ms.gov/docs/with_8935010.pdf • Withholding on checks delivered outside of the US:

1. If the individual is requesting the check be delivered outside of the US and they are certifying that they are a US Citizen, not a nonresident alien; and not an expatriate, then withholding would default to the 10% for IRA distributions;



2. If the individual is requesting the check be delivered outside of the US and they do not certify anything, withholding would default to the 30% for NRAs.

c. If you completed section 6a or 6b, check one of the following boxes:  I revoke all previous state income tax withholding elections and agree to apply the state tax withholding election above to all future distributions from this plan.  This state income tax withholding election will apply only to the current distribution. My previous state tax withholding elections will remain in effect for all future plan distributions. 7 Method of Payment 1.  Mail check to the address listed in Section 1, above. 2.  Deposit to my Citibank:   Checking Account or Money Market Account   Day to Day Savings Account

Item RPS036 (Rev. 4/14) Pkg. 25

Account Number: ______________________________________

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IRA and Roth IRA Withdrawal and Tax Withholding Election Form 8 By Signing Below • You authorize and direct us to make a withdrawal from the above Citibank IRA in the manner and for the reason indicated. • You affirm that the withdrawal is permitted under the Citibank IRA and meets all legal requirements of the Internal Revenue Code. _________________________________________________________________________________________________________________________________________ Print Name of Individual Receiving Funds

Signature

Date

For default rollovers of certain employer plans to Citibank, signature notarization of this form is required for withdrawals. Verification: an officer of a bank or trust company must complete this section.

Note to Branches: Be sure to date stamp form.

Name of Bank

Date

Signature of Officer/Title

Notarization: A signature/Notary Public must complete this section California Only State of California County of _________________________________________________________ On _________________________________________________ before me, _______________________________________________________ personally appeared

(Date)

(here insert name and title of the officer)

________________________________________________________________________ who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. __________________________________________________________________ Notary Public Signature

Notary Public Seal

All States except California State of ___________________________________________________________ County of _________________________________________________________ On _________________________________________________ before me came ______________________________________________________________________ (Date)

to me known to be the person described in, and who executed the foregoing instrument, and acknowledged that (s)he executed the same. __________________________________________________________________ Notary Public Signature

Notary Public Seal

Branch Use Only: A copy of this form must be pouched and sent to RPS Operations if customer checked the box to revoke previous withholding elections in Sections 5c or 6c. Check the box below if the distribution request was processed through NBS.  Distribution request processed through NBS. Date Stamp:

Item RPS036 (Rev. 4/14) Pkg. 25

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State Tax Information for IRAs (Traditional, SEP, SARSEP, Roth) Effective 1/2/2014 •• You may specify a percentage amount to be withheld for state income tax by completing Section 6 on the IRA and Roth IRA Withdrawal and Tax Withholding Election Form. We will withhold at least the state-required minimum amount when such a minimum applies. •• In general, state withholding requirements do not apply to Roth IRAs. •• State income tax rates are subject to change. Consult your tax advisor for more information and the latest rates for your state. State of Residence

State Income Tax Withholding Information

Arkansas

3%

California

10% of Computed Federal Tax

Delaware

5% minimum

District of Columbia

8.95%

Iowa

5.00%

Georgia

Under $8,000 = 2% $8,000 - $10,000 = 3% $10,001 - $12,000 = 4% $12,001 - $15,000 = 5% >$15,000 = 6%

Kansas

4.5%

Maine

5%

Massachusetts

5.2%

Michigan

4.25%

Mississippi

Withholding rates determined from table by participant

Nebraska

5%

North Carolina

4%

Oklahoma

5%

Oregon

8%

South Carolina

7%

Vermont

24% of Federal withholding amount

© 2014 Citigroup Inc. Citibank, N.A. Member FDIC. Citi and Arc Design is a registered service mark of Citigroup. 1209337 9864 05/14

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