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The document is a SAFE-HARBOR-IRA® Distribution Request Form from Centier Bank, designed for IRA owners to request distributions from their accounts. It includes sections for personal information, reasons for distribution (such as premature withdrawal, normal distribution, disability, death, divorce, or correction of excess contributions), payment instructions, and federal income tax withholding options. The form requires the signature of the IRA owner or beneficiary to authorize the transaction.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your IRA Owner Information. Fill in your Name, Account Number, Address, Phone, Date of Birth, and Social Security Number accurately.
Select the Reason for Distribution by checking the appropriate box. Ensure you provide any necessary attachments as indicated for options like Disability or Death.
In the Payment Instructions section, specify the Payment Amount. Choose between a gross distribution of the entire account balance or a partial amount.
Indicate your preferred Payment Method. If opting for a check, ensure your address is correct. For direct deposits, provide details such as Bank Name, ABA Routing Number, and Account Number.
Decide on Federal Income Tax Withholding preferences and fill in the required fields accordingly.
Finally, review all information for accuracy before signing and dating the form at the bottom.

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