This is a sample of a form that could be used for documentation and to request an initial distribution under IRC Section 72(t)

This is a sample of a form that could be used for documentation and to request an initial distribution under IRC Section 72(t). While there is no requirement that a SEPP Plan be reduced to writing, it will help to document the assumptions, calculations and distributions. We make no warranties or representations regarding the suitability or usability of this sample form in your distribution planning.

Remember, the SEPP plan is effective on the date of the first distribution and the interest rate selected must also be selected based on the maximum interest rate on the date of the first distribution. Make sure that you also check out our Planning Pointers before you implement your SEPP plan.

Account Owner's Name: __________________________________

Account Owner's Date of Birth: ___/____/______

Beneficiary's Date of Birth: ___/____/______(for Joint calculations)

First Distribution Date: ___/____/______

1)	Calculation Method
		Minimum Distribution
		Amortization Method
		Annuity Method
	To comply with RR 2002-62, all calculations should be done using the Annuity 2003 table.
2)	Life Expectancy [LE]
		Single Life Expectancy
		Joint Life Expectancy
3)	Interest Rate: ________% for Amortization and Annuity Methods.
	To comply with RR 2002-62, the maximum rate should be limited to 120% of the Federal Mid-Term AFR for either of the two months immediately preceeding the month that the first payment is to be made. Once established, it should remain fixed.
4)	Annual Recalculation
		Annual Recalculation of Age, Interest Rate and IRA Balance
		No Recalculation
5)	Account: Balance: $_____________ as of ___/___/______ To comply with RR 2002-62, the initial valuation date should probably be the December 31 of the prior year, or on a date within a reasonable period before that year's distribution.
6)	Calculated Annual Distribution: Amount: $____________
7)	Recalculation Date: If selected, Annual Recalculation will be determined as of _____ (Month) and _____ (Day) of each year based on the account balance as of 12/31 of the previous year.
8)	Recalculation Interest Rate: If Annual Recalculation is selected, the interest rate used will be determined as of the "Recalculation Date" and will be based on the highest of the 120% Mid-Term Applicable Federal Rate during the two months immediately preceding the "Recalculation Date".
9)	Stub-Year: The first year 'will' or 'will not' be treated as a stub year. If a stub-year is selected, the first year distribution will be a prorata share of the Calculated Annual Distribution resulting in a first year distribution amount of $_______________.
10)	IRA Accounts: The following IRA Accounts are included in my initial calculations: ____________________________________________________________________________________