Form   5305-R                      Roth Individual Retirement Trust Account                                Do not file 
(Rev. April 2017)                                                                                          with the Internal 
Department of the Treasury            (Under section 408A of the Internal Revenue Code)                    Revenue Service 
Internal Revenue Service 
Name of grantor                                            Date of birth of grantor             Account number 

Address of grantor 

                                                                                                Check if amendment .      . .         ▶
Name of trustee                            Address or principal place of business of trustee 

The grantor named above is establishing a Roth individual retirement account (Roth IRA) under section 408A to provide for his or 
her retirement and for the support of his or her beneficiaries after death. 
The trustee named above has given the grantor the disclosure statement required by Regulations section 1.408-6. 
The grantor has assigned the trust                                                  $ . 
The grantor and the trustee make the following agreement. 

                                                           Article I 
Except in the case of a qualified rollover contribution described in section 408A(e) or a recharacterized contribution described in 
section 408A(d)(6), the trustee will accept only cash contributions up to $5,500 per year for 2013 through 2017. For individuals who 
have reached the age of 50 by the end of the year, the contribution limit is increased to $6,500 per year for 2013 through 2017. For 
years after 2017, these limits will be increased to reflect a cost-of-living adjustment, if any.

                                                           Article II 
1. The annual contribution limit described in Article I is gradually reduced to $0 for higher income levels. For a grantor who is single 
or treated as single, the annual contribution is phased out between adjusted gross income (AGI) of $118,000 and $133,000; for a 
married grantor filing jointly, between AGI of $186,000 and $196,000; and for a married grantor filing separately, between AGI of $0 
and $10,000. These phase-out ranges are for 2017. For years after 2017, the phase-out ranges, except for the $0 to $10,000 range, 
will be increased to reflect a cost-of-living adjustment, if any. Adjusted gross income is defined in section 408A(c)(3). 

2. In the case of a joint return, the AGI limits in the preceding paragraph apply to the combined AGI of the grantor and his or her 
spouse.

                                                           Article III 
The grantor’s interest in the balance in the trust account is nonforfeitable. 

                                                           Article IV 
1. No part of the trust account funds may be invested in life insurance contracts, nor may the assets of the trust 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 trust 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 V 
1. If the grantor dies before his or her entire interest is distributed to him or her and the grantor’s surviving spouse is not the  
designated beneficiary, the remaining interest will be distributed in accordance with paragraph (a) below or, if elected or there is no 
designated beneficiary, in accordance with paragraph (b) below. 
(a) The remaining interest will be distributed, starting by the end of the calendar year following the year of the grantor’s death, over 
the designated beneficiary’s remaining life expectancy as determined in the year following the death of the grantor. 
(b) The remaining interest will be distributed by the end of the calendar year containing the fifth anniversary of the grantor’s death. 
2. The minimum amount that must be distributed each year under paragraph 1(a) above 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 designated beneficiary using the attained age of the beneficiary in the year following the year of the grantor’s 
death and subtracting 1 from the divisor for each subsequent year. 
3. If the grantor’s surviving spouse is the designated beneficiary, such spouse will then be treated as the grantor. 

                                                           Article VI 
1. The grantor agrees to provide the trustee with all information necessary to prepare any reports required by sections 408(i) and 
408A(d)(3)(E), Regulations sections 1.408-5 and 1.408-6, or other guidance published by the Internal Revenue Service (IRS). 
2. The trustee agrees to submit to the IRS and grantor the reports prescribed by the IRS. 

                                           Cat. No. 25093N                                         Form  5305-R  (Rev. 4-2017) 

Form 5305-R (Rev. 4-2017)                                                                                                                       Page  2 

                                                         Article VII 
Notwithstanding any other articles which may be added or incorporated, the provisions of Articles I through IV and this sentence will 
be controlling. Any additional articles inconsistent with section 408A, the related regulations, and other published guidance will be 
invalid. 
                                                         Article VIII 
This agreement will be amended as necessary to comply with the provisions of the Code, the related regulations, and other 
published guidance. Other amendments may be made with the consent of the persons whose signatures appear below. 
                                                         Article IX 
Article IX 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. 

Grantor’s signature                                                                                          Date 

Trustee’s signature                                                                                          Date 

Witness’ signature                                                                                           Date 
                          (Use only if signature of the grantor or the trustee is required to be witnessed.) 
General Instructions                       income. For more information on Roth                              Article V. This article describes how  
                                           IRAs, including the required disclosures                          distributions will be made from the Roth  
Section references are to the Internal     the trustee must give the grantor, see                            IRA after the grantor’s death. Elections  
Revenue Code unless otherwise noted.       Pub. 590-A, Contributions to Individual                           made pursuant to this article should be  
                                           Retirement Arrangements (IRAs), and                               reviewed periodically to ensure they  
Purpose of Form                            Pub. 590-B, Distributions from Individual                         correspond to the grantor’s intent. Under 
Form 5305-R is a model trust account       Retirement Arrangements (IRAs).                                   paragraph 3 of Article V, the grantor’s  
agreement that meets the requirements                                                                        spouse is treated as the owner of the  
of section 408A. However, only Articles I  Definitions                                                       Roth IRA upon the death of the grantor,  
through VIII have been reviewed by the     Trustee. The trustee must be a bank or                            rather than as the beneficiary. If the  
IRS. A Roth individual retirement          savings and loan association, as defined                          spouse is to be treated as the  
account (Roth IRA) is established after    in section 408(n), or any person who has                          beneficiary, and not the owner, an  
the form is fully executed by both the     the approval of the IRS to act as trustee.                        overriding provision should be added to  
                                                                                                             Article IX. 
individual (grantor) and the trustee. This Grantor. The grantor is the person who  
account must be created in the United      establishes the trust account.                                    Article IX. Article IX and any that follow  
States for the exclusive benefit of the                                                                      it may incorporate additional provisions  
grantor and his or her beneficiaries.                                                                        that are agreed to by the grantor and  
                                           Specific Instructions 
Do not file Form 5305-R with the IRS.                                                                        trustee to complete the agreement. They 
Instead, keep it with your records.        Article I. The grantor may be subject to                          may include, for example, definitions,  
                                           a 6% tax on excess contributions if                               investment powers, voting rights,  
Unlike contributions to traditional        (1) contributions to other individual                             exculpatory provisions, amendment and  
individual retirement arrangements,        retirement arrangements of the grantor                            termination, removal of the trustee,  
contributions to a Roth IRA are not        have been made for the same tax year,                             trustee’s fees, state law requirements,  
deductible from the grantor’s gross        (2) the grantor’s adjusted gross income                           beginning date of distributions,  
income; and distributions after 5 years    exceeds the applicable limits in Article II                       accepting only cash, treatment of  
that are made when the grantor is 591/2    for the tax year, or (3) the grantor’s and                        excess contributions, prohibited  
years of age or older or on account of     spouse’s compensation is less than the                            transactions with the grantor, etc. Attach 
death, disability, or the purchase of a    amount contributed by or on behalf of                             additional pages if necessary. 
home by a first-time homebuyer (limited    them for the tax year. 
to $10,000), are not includible in gross 

                                                                                                                         Form  5305-R  (Rev. 4-2017)