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Form 5305-RA Roth Individual Retirement Custodial 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 depositor Date of birth of depositor Account number

Address of depositor

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

The depositor 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 custodian named above has given the depositor the disclosure statement required by Regulations section 1.408-6.
The depositor assigned the custodial account $ .
The depositor and the custodian 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 custodian 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 depositor and his or her
spouse.
Article III
The depositor’s interest in the balance in the custodial account is nonforfeitable.
Article IV
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 V
1. If the depositor dies before his or her entire interest is distributed to him or her and the depositor’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 depositor’s death,
over the designated beneficiary’s remaining life expectancy as determined in the year following the death of the depositor.
(b) The remaining interest will be distributed by the end of the calendar year containing the fifth anniversary of the depositor’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 depositor’s
death and subtracting 1 from the divisor for each subsequent year.
3. If the depositor’s surviving spouse is the designated beneficiary, such spouse will then be treated as the depositor.
Article VI
1. The depositor agrees to provide the custodian 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).
Cat. No. 25094Y Form 5305-RA (Rev. 4-2017)

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Form 5305-RA (Rev. 4-2017) Page 2
2. The custodian agrees to submit to the IRS and depositor the reports prescribed by the IRS.
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.

Depositor’s signature Date

Custodian’s signature Date

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

Form 5305-RA (Rev. 4-2017)

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