IRA Periodic Distribution Form

Mutual Fund IRA Periodic Distribution Form

First Name

MI

Last Name

Daytime Phone Number (include area code)

Residence

Work

Cell

Type of Request

Establish a new periodic distribution plan.

Change an existing periodic distribution plan.

Distribution Details

From: IRA Account Registration Number

From: Current Registration Name(s)

Distribution Reason

Normal

Premature Distribution

Disability

Substantially Equal Periodic Payment Distribution

Invest in my existing non-IRA Victory Funds Account

Transfer to Financial Institution by Electronic Funds Transfer(EFT)

Send me a Check

Banking Information

NOTE: Bank Account Owner name(s) and this investment account owner name(s) should be identical. You will need to attach a voided check, deposit slip, or financial institution statement with the account number and all owner names preprinted on it, if opening a new Bank Account.

Select Bank Account

Name of Financial Institution

Type of Account

Checking

Savings

Name of Account Owner(s)

Transit Routing Number (9-digit number in lower left corner of check)

Account Number

In general, retirement distributions you receive are subject to federal and, in some states, state income tax. IRS Regulations require withholding of 10% federal income taxes from retirement distributions unless you provide a different election below. If no tax election is made, we are required to withhold 10% of your distribution for Federal Income Tax purposes (excluding Roth IRA distributions). Prior to making your federal income tax withholding election, refer to the Marginal Rate Tables and the General Instructions found in the attached IRS Form W-4R. You may use these tables to help you select the appropriate withholding rate for this distribution.

Please make your withholding election below rather than on Form W-4R.

Federal Tax Withholding Election (Select One)

I DO NOT want to have federal income tax withheld from my retirement plan distribution.

I DO want to have federal income tax withheld from my retirement plan distribution at the rate of

NOTE: The IRS Form W-4R is for information only. You are not required to complete the IRS Form W-4R.

State Tax Withholding Election (Select One)

If you reside in a certain mandatory withholding state, we are required to withhold state income tax at the rate prescribed by your state (excluding Roth IRA distributions). Some states require an additional form to be completed for your state withholding election. To ensure your distribution request is not delayed by required additional paperwork, if your state has state income tax, please contact Victory Funds to determine the requirements for your state. You may also contact your state or consult with a tax advisor regarding your specific situation.

Roth IRA accounts are not typically subjected to Federal or State income tax. Please review your selection before continuing.

If no state tax election is made, we will automatically apply state withholding (if required by your state) at the minimum rate based on your state of residency.

The state of residence in the legal address on this IRA will determine the state income tax withholding requirements for your distributions.

I DO NOT want to have state income tax withheld from my retirement plan distribution.

I DO want to have state income tax withheld in accordance with the minimum amount or percentage as determined by the requirements of my state of residence. If your state does not provide a minimum percentage no state income tax withholding will be withheld.

I DO want to have state income tax withheld from my retirement plan distribution (must be higher than the state minimum).

If no tax is withheld, you may still be subject to federal and state tax on this income. You may also be subject to IRS penalties under rules for estimated tax if your payments of estimated tax and federal/state tax withheld, if any, are not sufficient. Your withholding election will remain in effect until revoked by you.

For your protection, we may require additional verification of your identity and/or instructions before accepting your transaction. The amount of money that you receive will depend on the execution price once we have verified your identity and/or instructions and the order is in proper form. Due to market fluctuations while we obtain verification, the amount you ultimately receive could be less than the amount at the time you initiated this transaction. [If we are unable to reach you to verify this transaction within five days, we may cancel this transaction.] We are not liable for any delayed executions, canceled orders, or requests not acted upon as a result of the verification of your identity and/or instructions.

If I have selected EFT of my distribution by Victory Funds and its transfer agent, I authorize Victory Funds to begin, and the financial institution named to accept, electronic deposits (credits) and withdrawals (debits) to my designated account(s) and to reverse, if necessary, any deposits or withdrawals made in error to my account(s). Automated debit or credit entries shall constitute my receipt for the transaction(s). This authority is to remain in full force and effect until Victory Funds has received written or phone notification from me of its termination at such time and in such manner as to give Victory Funds reasonable opportunity to act on it. I also understand Victory Funds may terminate the EFT instructions from my mutual fund account(s) at any time in its sole discretion. I acknowledge that the origination of ACH transactions to my account(s) must comply with the provisions of U.S. law.

Tools & Resources

Insights

Mutual Fund IRA Periodic Distribution Form

Personal Information

IRA Account Selection

Distribution Instructions

Banking Information

Federal and State Tax Withholding

Read & Acknowledge