FIRSTBANK PUERTO RICO INDIVIDUAL RETIREMENT ACCOUNT TRUSTS Individual Retirement Accounts Disclosure This Individual Retirement Account (IRA)

(1) the number shown on this form is my correct Taxpayer Identification Number (or I am waiting for a number to be issued to me), and (2) I am not subject to backup

When you open an account, you will be asked for your name, date of birth (for a natural person), your residential address or principal place of business, and mailing address,

I elect TO have the following dollar amount or percentage from my retirement account distribution withheld for state income taxes (for residents of states that allow voluntary

 I want the minimum state income tax withheld from distributions from this account.  I want state income tax of _______% withheld from distributions from

Automatic rate: I want Federal Income Tax at the rate of 10% withheld from my lump sum distribution, or at the married rate claiming 3 exemptions from my periodic payment

One-Time Distribution — Select one option and proceed to Section 4 — Federal Income Tax Withholding (continued) Required Minimum Distribution (70½ years of age)A. □ Please redeem $

ACH instructions already established for my IRA OR Bank Account Information below ** Wire transfer my One Time Distribution (not available for Systematic Distributions) to

Annual limitations for Roth IRA contributions, Modified Adjusted Gross Income (MAGI) deductibility limits for those who are active participants in employer plans and those seeking