Self-Directed Roth IRA | Preferred Trust Company

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ROTH IRA Application

Where did you hear about us?*

SECTION 1 | Type of Account and Title

Account Type*

ROTH

Inherited IRA

Relationship to Original IRA Owner*

If this is an Inherited ROTH IRA, the following information must be completed:

DOB of Original IRA Owner*

Date of Death of Original IRA Owner*

Vesting (Ownership Title)*

Example: ROTH: Preferred Trust Company, LLC FBO (For the Benefit Of) Jane Doe, Roth IRA or INHERITED: Preferred Trust Company, LLC FBO Jane Doe, Inherited Roth IRA John Doe

SECTION 2 | IRA Account Owner Information

To help the government fight the funding of terrorism and money laundering activities, Federal law (Section 326 of the USA PATRIOT Act of 2001) requires all financial institutions to obtain, verify and record information that identifies each individual or institution who opens an account with Preferred Trust Company. When you open an account, we are required to obtain your name, address, date of birth, social security number or tax identification number and other information that will allow us to identify you. As appropriate, we may also ask to see your driver's license or other identifying documents. This information will be verified to ensure the identity of all persons opening an account. The information may be compared to information obtained through third party sources, as permitted by law. If we cannot verify this information, your account may not be opened, or it may be restricted and/or closed. Preferred Trust Company is not responsible for any losses or damages including, but not limited to, lost opportunities you may incur.

Name*

First Middle Initial Last

SSN*

Date of Birth*

Email*

Phone*

Cell Phone

SMS/Text Opt In

Yes, I would like to receive account updates and messages from Preferred Trust via text/SMS. (Message and data rates may apply.)

Address (IRA Account Holder)*

Please use a two letter state abbreviation

Street Address City State ZIP Code

Government Issued Identification

Please complete the information below; approved documents include any unexpired, government issued photo ID including a driver’s license, U.S. passport, state issued photo ID card or military ID.

Photo Identification Type*

ID Number*

State Issued

Please use a two letter abbreviation

State Issued*

Issue Date*

Please enter issue date

Expiration Date*

Please enter expiration date

SECTION 3 | Automatic Contribution (not applicable to Inherited IRAs)

Preferred Trust Company accepts automatic cash contributions to an IRA account. There is no fee associated with automatic contribution transactions. Funds are deducted from a checking or savings account. The financial institution must be a member of the Automated Clearing House (ACH). Deductions will be processed on or about the 5th and/or the 20th of each month. The minimum automatic contribution is $25.00 and the maximum is dependent on the allowable maximum amount determined by the IRS for the current year. This amount is set forth in the IRS Publication 590-A for the current year. Preferred Trust Company reserves the right to cancel an automatic contribution should the ACH deduction be rejected due to insufficient funds or incorrect account information.

Frequency

Monthly on the 5th

Monthly on the 20th

Twice Monthly on 5th and 20th

Deduction

Deduction Amount (minimum $25.00)

Bank Information

Name of Financial Institution

Account Type

Checking

Savings

Bank Account Number

Bank Routing Number

SECTION 4 | Beneficiary Designation Information

At the time of my death, the primary beneficiaries named below will receive my IRA assets. If all of my primary beneficiaries die before me, the contingent beneficiaries named below will receive my IRA assets. In the event a beneficiary dies before me, such beneficiaries share will be reallocated on a pro-rata basis to the other beneficiaries that share the deceased beneficiaries classification as a primary or contingent beneficiary. If all of the beneficiaries die before me, my IRA assets will be paid to my estate. If no percentages are assigned to beneficiaries, the beneficiaries will share equally. If the percentage total for each beneficiary classification does not equal 100%, any remaining percentage will be divided equally among the beneficiaries within such class. This designation revokes and supersedes all earlier beneficiary designations which may apply to this IRA.

Quantify Beneficiaries*

How Many Beneficiaries Would You Like to Add?

Beneficiary #1

Beneficiary Type (#1)*

Primary

Share Percentage (Beneficiary #1)*

Please DO NOT include “%” in your field. Please enter percentage as a number only: example: 100

Name of Beneficiary (Beneficiary #1)*

Maximum of 30 characters per field

First Last

Beneficiary Date of Birth (Beneficiary #1)*

SSN or Taxpayer ID (Beneficiary #1)*

Relationship to IRA Owner (Beneficiary #1)*

Address (Beneficiary #1)*

Please use a two letter state abbreviation

Street Address City State ZIP Code

Phone (Beneficiary #1)*

Email (Beneficiary #1)*

Beneficiary #2

Beneficiary Type (#2)*

Primary

Contingent

Share Percentage (Beneficiary #2)*

Please DO NOT include “%” in your field. Please enter percentage as a number only: example: 100

Name of Beneficiary (Beneficiary #2)*

Maximum of 30 characters per field

First Last

Beneficiary Date of Birth (Beneficiary #2)*

SSN or Taxpayer ID (Beneficiary #2)*

Relationship to IRA Owner (Beneficiary #2)*

Address (Beneficiary #2)*

Please use a two letter state abbreviation

Street Address City State ZIP Code

Phone (Beneficiary #2)*

Email (Beneficiary #2)*

Beneficiary #3

Beneficiary Type (#3)*

Primary

Contingent

Share Percentage (Beneficiary #3)*

Please DO NOT include “%” in your field. Please enter percentage as a number only: example: 100

Name of Beneficiary (Beneficiary #3)*

Maximum of 30 characters per field

First Last

Beneficiary Date of Birth (Beneficiary #3)*

SSN or Taxpayer ID (Beneficiary #3)*

Relationship to IRA Owner (Beneficiary #3)*

Address (Beneficiary #3)*

Please use a two letter state abbreviation

Street Address City State ZIP Code

Phone (Beneficiary #3)*

Email (Beneficiary #3)*

Beneficiary #4

Beneficiary Type (#4)*

Primary

Contingent

Share Percentage (Beneficiary #4)*

Please DO NOT include “%” in your field. Please enter percentage as a number only: example: 100

Name of Beneficiary (Beneficiary #4)*

Maximum of 30 characters per field

First Last

Beneficiary Date of Birth (Beneficiary #4)*

SSN or Taxpayer ID (Beneficiary #4)*

Relationship to IRA Owner (Beneficiary #4)*

Address (Beneficiary #4)*

Please use a two letter state abbreviation

Street Address City State ZIP Code

Phone (Beneficiary #4)*

Email (Beneficiary #4)*

Beneficiary #5

Beneficiary Type (#5)*

Primary

Contingent

Share Percentage (Beneficiary #5)*

Please DO NOT include “%” in your field. Please enter percentage as a number only: example: 100

Name of Beneficiary (Beneficiary #5)*

Maximum of 30 characters per field

First Last

Beneficiary Date of Birth (Beneficiary #5)*

SSN or Taxpayer ID (Beneficiary #5)*

Relationship to IRA Owner (Beneficiary #5)*

Address (Beneficiary #5)*

Please use a two letter state abbreviation

Street Address City State ZIP Code

Phone (Beneficiary #5)*

Email (Beneficiary #5)*

SECTION 5 | Spousal Consent

This section should be reviewed if either the trust or the residence of the account owner who may reside in a community or marital property state and the account owner is married. Due to the consequences of giving up one’s community property interest if the spouse is not identified as a 50% beneficiary to the IRA, the spouse is advised to seek legal opinion and may be required (if in a community or marital property state) to sign this section prior to the IRA being opened. If the spouse is not identified as a 50% beneficiary to the IRA and the account owner is in a community or marital property state, the spouse will be required to consent to grant the account owner any interest they have in the funds or property deposited in this account and consent to the beneficiary designations identified by the account owner and assume full responsibility for any adverse consequences that may result.

Marital Status*

I am Married. I understand that if I designate a primary beneficiary other than my spouse, my spouse must consent. A Preferred Trust Company Client Services Representative will follow-up to obtain the signature of the spouse separately.

I am Not Married. I understand that if I marry in the future, I must complete a new Designation of Beneficiary form, which includes the spousal consent documentation.

IRA Owner Initials*

(Married)

IRA Owner Initials*

(Unmarried)

SECTION 6 | Interested Party Designation

Complete the information below only if you wish to authorize an individual to receive information on your account. I hereby designate the below-mentioned Interested Party Designee subject to all applicable terms and provisions stated in the Custodial Agreement. I authorize this Interested Party Designee to receive statements and other account information from Preferred Trust Company as Custodian via written, telephonic or electronic communications. I agree that Preferred Trust Company as Custodian is under no duty to investigate or inquire about the Interested Party Designee. I understand that this individual is not authorized to execute transactions on my behalf. I understand that I may revise this information at any time by giving written notice to Preferred Trust Company. If an IRA Account Owner would like to grant an Interested Party Agent authorization to execute transactions on their behalf, Preferred Trust Company as Custodian requires a Limited Power of Attorney on file.

Individual/Financial Representative Name

Company/Broker Dealer Affiliation (if applicable)

Interested Party Address

Please use a two letter state abbreviation

Street Address City State ZIP Code

Interested Party Phone

Interested Party Email

SECTION 7 | Privacy Policy

I have read and agree to the following:*

SECTION 8 | Preferred Trust Company Disclosure Statement

Company Disclosure Statement

I have read and agree to the following:*

Disclosure Statement

SECTION 9 | Preferred Trust Company Custodial Agreement

Custodial Agreement (Roth)

I have read and agree to the following:*

Custodial Agreement

SECTION 10 | Preferred Trust Company Fee Schedule

Fee Schedule

I have read and agree to the following:*

Fee Schedule

SECTION 11 | Acknowledgement Signatures

Important Information About Procedures for Opening a New Account
To help the government fight the funding of terrorism and money laundering activities, Federal law (Section 326 of the USA PATRIOT Act of 2001) requires all financial institutions to obtain, verify and record information that identifies each individual or institution who opens an account with Preferred Trust Company. When you open an account, we are required to obtain your name, address, date of birth, social security number or tax identification number and other information that will allow us to identify you. As appropriate, we may also ask to see your driver's license or other identifying documents. This information will be verified to ensure the identity of all persons opening an account. The information may be compared to information obtained through third party sources, as permitted by law. If we cannot verify this information, your account may not be opened, or it may be restricted and/or closed. Preferred Trust Company is not responsible for any losses or damages including, but not limited to, lost opportunities you may incur.

Application and signatures are valid for 120 days from the date of original signature.
I certify that the information provided by me on this Application is accurate, and that I have received a copy and agree to be bound by the terms and amendment thereto of the Privacy Policy, Disclosure Agreement, Custodial Agreement, Fee Schedule, and Form 5305 (Individual Retirement Trust Account). I assume sole responsibility for all consequences relating to my actions concerning this IRA. I understand that I may revoke this IRA on or before seven (7) days after the date of establishment. I have not received any financial, tax or legal advice from Preferred Trust Company, LLC, and will seek the advice of my own tax or legal professional to ensure my compliance with related laws. I release and agree to hold Preferred Trust Company, LLC harmless against any and all claims or losses arising from my actions.

Electronic Signature
The parties agree that the electronic signature of a party to this Agreement shall have the same legal validity and enforceability as a manually executed signature or use of a paper-based recordkeeping system to the fullest extent permitted by applicable law, including the Federal Electronic Signatures in Global and National Commerce Act or any similar state law based on the Uniform Electronic Transactions Act, and the parties hereby waive any objection to the contrary. This electronic signature shall be effective to bind this Agreement. The parties agree that any electronically signed document (including this Agreement) shall be deemed (i) to be “written” or “in writing,” (ii) to have been signed and (iii) to constitute a record established and maintained in the ordinary course of business and an original written record when printed from electronic files. Such paper copies or “printouts,” if introduced as evidence in any judicial, arbitral, mediation or administrative proceeding, will be admissible as between the parties to the same extent and under the same conditions as other original business records created and maintained in documentary form. Neither party shall contest the admissibility of true and accurate copies of electronically signed documents based on the best evidence rule or as not satisfying the business records exception to the hearsay rule. For purposes hereof, “electronic signature” means a manually signed original signature that is then transmitted by electronic means; “transmitted by electronic means” means sent in the form of a facsimile or sent via the internet as a “pdf” (portable document format) or other replicating image attached to an e-mail message; and, “electronically signed document” means a document transmitted by electronic means and containing, or to which there is affixed, an electronic signature.

Signature of IRA Account Owner*

Date*