Form  5305-SA               SIMPLE Individual Retirement Custodial Account                                             Do not file 
(Rev. April 2017)                                                                                                      with the Internal  
Department of the Treasury  (Under section 408(p) of the Internal Revenue Code)                                        Revenue Service 
Internal Revenue Service 
Name of participant                                       Date of birth of participant           Account number 

Address of participant                                                                           Check if transfer SIMPLE IRA  .  ▶
                                                                                                 Check if amendment .  .          .               .  ▶
Name of custodian                                 Address or principal place of business of custodian

The participant named above is establishing a savings incentive match plan for employees of small employers individual retirement account  
(SIMPLE IRA) under sections 408(a) and 408(p) to provide for his or her retirement and for the support of his or her beneficiaries after death. 
The custodian named above has given the participant the disclosure statement required by Regulations section 1.408-6.  
The participant and the custodian make the following agreement. 
                                                                    Article I 
The custodian will accept cash contributions made on behalf of the participant by the participant’s employer under the terms of a SIMPLE IRA plan 
described in section 408(p). In addition, the custodian will accept transfers or rollovers from other SIMPLE IRAs of the participant and, after the 2-year 
period of participation defined in section 72(t)(6), transfers or rollovers from any eligible retirement plan (as defined in section 402(c)(8)(B)) other than a 
Roth IRA or a designated Roth account. No other contributions will be accepted by the custodian.
                                                                    Article II 
The participant’s interest in the balance in the custodial account is nonforfeitable. 
                                                                    Article III 
1. No part of the custodial account funds may be invested in life insurance contracts, nor may the assets of the custodial account be 
commingled with other property except in a common trust fund or common investment fund (within the meaning of section 408(a)(5)). 
2. No part of the custodial account funds may be invested in collectibles (within the meaning of section 408(m)) except as otherwise permitted 
by section 408(m)(3), which provides an exception for certain gold, silver, and platinum coins, coins issued under the laws of any state, and 
certain bullion. 
                                                                    Article IV 
1. Notwithstanding any provision of this agreement to the contrary, the distribution of the participant’s interest in the custodial account shall 
be made in accordance with the following requirements and shall otherwise comply with section 408(a)(6) and the regulations thereunder, the  
provisions of which are herein incorporated by reference. 
2.  The participant’s entire interest in the custodial account must be, or begin to be, distributed not later than the participant’s required 
beginning date, April 1 following the calendar year in which the participant reaches age 701/2. By that date, the participant may elect, in a 
manner acceptable to the custodian, to have the balance in the custodial account distributed in: 
(a) A single sum or 
(b) Payments over a period not longer than the life of the participant or the joint lives of the participant and his or her designated beneficiary. 
3. If the participant dies before his or her entire interest is distributed to him or her, the remaining interest will be distributed as follows. 
(a) If the participant dies on or after the required beginning date and: 
      (i)  The designated beneficiary is the participant’s surviving spouse, the remaining interest will be distributed over the surviving spouse’s life  
expectancy as determined each year until such spouse’s death, or over the period in paragraph (a)(iii) below if longer. Any interest remaining  
after the spouse’s death will be distributed over such spouse’s remaining life expectancy as determined in the year of the spouse’s death and  
reduced by 1 for each subsequent year, or, if distributions are being made over the period in paragraph (a)(iii) below, over such period. 
      (ii) The designated beneficiary is not the participant’s surviving spouse, the remaining interest will be distributed over the beneficiary’s  
remaining life expectancy as determined in the year following the death of the participant and reduced by 1 for each subsequent year, or over  
the period in paragraph (a)(iii) below if longer. 
      (iii) There is no designated beneficiary, the remaining interest will be distributed over the remaining life expectancy of the participant as  
determined in the year of the participant’s death and reduced by 1 for each subsequent year. 
(b) If the participant dies before the required beginning date, the remaining interest will be distributed in accordance with paragraph (i) below or, if  
elected or there is no designated beneficiary, in accordance with paragraph (ii) below. 
      (i) The remaining interest will be distributed in accordance with paragraphs (a)(i) and (a)(ii) above (but not over the period in paragraph (a)(iii),  
even if longer), starting by the end of the calendar year following the year of the participant’s death. If, however, the designated beneficiary is  
the participant’s surviving spouse, then this distribution is not required to begin before the end of the calendar year in which the participant  
would have reached age 701/2. But, in such case, if the participant’s surviving spouse dies before distributions are required to begin, then the  
remaining interest will be distributed in accordance with paragraph (a)(ii) above (but not over the period in paragraph (a)(iii), even if longer), over such  
spouse’s designated beneficiary’s life expectancy, or in accordance with paragraph (ii) below if there is no such designated beneficiary. 
      (ii) The remaining interest will be distributed by the end of the calendar year containing the fifth anniversary of the participant’s death. 
4. If the participant dies before his or her entire interest has been distributed and if the designated beneficiary is not the participant’s surviving  
spouse, no additional contributions may be accepted in the account. 
5. The minimum amount that must be distributed each year, beginning with the year containing the participant’s required beginning date, is  
known as the “required minimum distribution” and is determined as follows. 

                                                  Cat. No. 23698C                                    Form 5305-SA  (Rev. 4-2017) 

Form 5305-SA (Rev. 4-2017)                                                                                                                               Page  2 
(a) The required minimum distribution under paragraph 2(b) for any year, beginning with the year the participant reaches age 701/2, is the            
participant’s account value at the close of business on December 31 of the preceding year divided by the distribution period in the uniform 
lifetime table in Regulations section 1.401(a)(9)-9. However, if the participant’s designated beneficiary is his or her surviving spouse, the required  
minimum distribution for a year shall not be more than the participant’s account value at the close of business on December 31 of the preceding 
year divided by the number in the joint and last survivor table in Regulations section 1.401(a)(9)-9. The required minimum distribution for a year 
under this paragraph (a) is determined using the participant’s (or, if applicable, the participant and spouse’s) attained age (or ages) in the year. 
(b) The required minimum distribution under paragraphs 3(a) and 3(b)(i) for a year, beginning with the year following the year of the  
participant’s death (or the year the participant would have reached age 701/2, if applicable under paragraph 3(b)(i)) is the account value at the     
close of business on December 31 of the preceding year divided by the life expectancy (in the single life table in Regulations section  
1.401(a)(9)-9) of the individual specified in such paragraphs 3(a) and 3(b)(i). 
(c) The required minimum distribution for the year the participant reaches age 701/2can      be made as late as April 1 of the following year. The        
required minimum distribution for any other year must be made by the end of such year. 
6. The owner of two or more IRAs (other than Roth IRAs) may satisfy the minimum distribution requirements described above by taking from  
one IRA the amount required to satisfy the requirement for another in accordance with the regulations under section 408(a)(6). 
                                                                    Article V 
1. The participant agrees to provide the trustee with all information necessary to prepare any reports required by sections 408(i) and 
408(l)(2) and Regulations sections 1.408-5 and 1.408-6. 
2. The custodian agrees to submit to the Internal Revenue Service (IRS) and participant the reports prescribed by the IRS. 
3. The custodian also agrees to provide the participant’s employer the summary description described in section 408(l)(2) unless this SIMPLE 
IRA is a transfer SIMPLE IRA. 
                                                                    Article VI 
Notwithstanding any other articles which may be added or incorporated, the provisions of Articles I through III and this sentence will be  
controlling. Any additional articles inconsistent with sections 408(a) and 408(p) and the related regulations will be invalid. 
                                                                    Article VII 
This agreement will be amended as necessary to comply with the provisions of the Code and the related regulations. Other amendments may  
be made with the consent of the persons whose signatures appear below. 
                                                                    Article VIII 
Article VIII may be used for any additional provisions. If no other provisions will be added, draw a line through this space. If provisions are  
added, they must comply with applicable requirements of state law and the Internal Revenue Code and may not imply that they have been reviewed or 
pre-approved by the IRS. 

Participant’s signature                                                                                          Date 
                                 (If an individual other than the participant signs this form for the participant, indicate the individual’s relationship to the participant.) 

Custodian’s signature                                                                                            Date 

Witness’ signature                                                                                               Date 
                        (Use only if signature of the participant or the custodian is required to be witnessed.) 

General Instructions                             Pub. 590-A, Contributions to Individual                         Specific Instructions 
                                                 Retirement Arrangements (IRAs); Pub. 590-B, 
Section references are to the Internal           Distributions from Individual Retirement                        Article IV. Distributions made under this  
Revenue Code unless otherwise noted.             Arrangements (IRAs); and Pub 560,                               article may be made in a single sum, periodic  
Purpose of Form                                  Retirement Plans for Small Business (SEP,                       payment, or a combination of both. The  
                                                 SIMPLE, and Qualified Plans).                                   distribution option should be reviewed in the  
Form 5305-S is a model custodial account                                                                         year the participant reaches age 701/2 to  
agreement that meets the requirements of         Definitions                                                     ensure that the requirements of section  
sections 408(a) and 408(p). However, only        Participant. The participant is the person                      408(a)(6) have been met. 
Articles I through VII have been reviewed by     who establishes the custodial account.                          Article VIII. Article VIII and any that follow it  
the IRS. A SIMPLE individual retirement          Custodian. The custodian must be a bank or                      may incorporate additional provisions that are 
account (SIMPLE IRA) is established after the    savings and loan association, as defined in                     agreed to by the participant and custodian to  
form is fully executed by both the individual    section 408(n), or any person who has the                       complete the agreement. They may include,  
(participant) and the custodian. This account    approval of the IRS to act as custodian.                        for example, definitions, investment powers,  
must be created in the United States for the                                                                     voting rights, exculpatory provisions,  
exclusive benefit of the participant and his or  Transfer SIMPLE IRA                                             amendment and termination, removal of the  
her beneficiaries.                               This SIMPLE IRA is a “transfer SIMPLE IRA”                      custodian, custodian’s fees, state law  
Do not file Form 5305-S with the IRS.            if it is not the original recipient of                          requirements, beginning date of distributions,  
Instead, keep it with your records.              contributions under any SIMPLE IRA plan.                        accepting only cash, treatment of excess  
For more information on SIMPLE IRAs,             The summary description requirements of                         contributions, prohibited transactions with the 
including the required disclosures the           section 408(l)(2) do not apply to transfer                      participant, etc. Attach additional pages if  
custodian must give the participant, see         SIMPLE IRAs.                                                    necessary. 
                                                                                                                               Form  5305-SA  (Rev. 4-2017)