Retirement Account Required Distribution Penalty Waiver Request Form
Use this form to request a review of a retirement account required distribution penalty waiver and provide the details needed to evaluate the request.
Applicant Information
Full Name
*
First Name
Middle Name
Last Name
Preferred Contact Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Retirement Account and Distribution Details
Retirement Account Type
*
Please Select
Traditional IRA
Roth IRA
401(k)
403(b)
457(b)
SEP IRA
SIMPLE IRA
Other retirement account type
Tax Year or Distribution Year
*
Date the Distribution Was Due or Missed
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Required Distribution Amount or Penalty Amount
Reason for Penalty Waiver Request
Reason Required Distribution Was Missed
*
Please Select
Administrative error
Medical emergency
Family emergency
Natural disaster
Financial hardship
Incorrect account information
Dependency on adviser or custodian
Other
Brief Explanation of Circumstances
*
Supporting Documents
Attached
Will be provided later
Requested Outcome
*
Approve penalty waiver
Consider waiver request
Other
Declaration
*
I certify that the information provided is accurate and is submitted in support of this penalty waiver request.
Submit Request
Should be Empty: