American Estate & Trust, LC
7251 W. Lake Mead Blvd., Ste 300
Las Vegas, NV 89128
Fax (702) 562-4122 Ph. (866) 654-6111
72(t) Early Withdrawal IRA
Supplemental Application Form
Note: This application provides information to be used to comply with the rules set out in Internal Revenue Code Sec. 72(t)(2)(A)(iv), which state
that the 10 percent penalty on early distributions prior to age 59 ½ from an IRA will not apply to a distribution which is part of a series of
substantially equal periodic payments. However, if your IRA is a traditional type, you will owe taxes on each year’s total payments, based on
your tax rate in effect at that time (Roth 72(t) payments are non-taxable). These taxes may require the filing of interim estimated tax returns.
Account Holder Ö Phone No: (_____) _____-_______ Soc. Sec. No: _______-_____-_______ Date of Birth: ____/____/_________
Type of IRA For the 72(t):
SIMPLE Estimated, Total Amount of 72(t) funds: $__________________
Select one of the following payment calculation methods:
Check Here If Converting All The Funds Of an Existing
AE-Trust IRA to a 72(t)
Use IRS calculation method which maximizes my 72(t) payments.
Use IRS calculation method which minimizes my 72(t) payments.
Select one of the following choices: I Wish To Receive 72(t) Payments At The Following Frequency:
I do want to see an illustration of my payment amounts.
I do not need to see an illustration of my payment amounts. I want the payments to begin on this date: ____/____/_________
Separate from t