EX-99.B14
Individual Retirement Account Agreement
"Invest in the companies
that invest in your sport" [sm]
0.00.XXXX.XXXX
xxx.xxxxxxxxxxxxxx.xxx
This application will open: XX Xxx 000
XXXXXXXXXXX XXX Xxxxxxxxxxxx, XX 00000
XXXX XXX
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9. Participant Information
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Name ______________________________________________________________________
Address ___________________________________________________________________
City _______________________________________ State ________ Zip ________
Home Phone #: ____-____-_______ Work Phone #: ____-____-______
Social Security Number ___-__-____ Date of Birth _______
US Citizen? Yes [ ] No [ ]
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10. Account Information
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Custodian: First Union National Bank
Sponsor of Plan: StockCar Stocks Mutual Fund
Initial Contribution $_____________ (Check type of XXX below. Only one box
may be checked.)
Traditional XXX
[ ] Traditional XXX for tax year __________
[ ] Rollover / Direct Rollover
[ ] Transfer from another Traditional XXX
Xxxx XXX
[ ] Regular Xxxx XXX for tax year ___________
[ ] Rollover Conversion Xxxx XXX
[ ] Contribution Conversion of $_____________
plus earnings of $_______________ for tax
year ____________
[ ] Transfer from another Xxxx XXX
[ ] Rollover from another Xxxx XXX
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11. Beneficiary(ies) Designation
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[ ] Primary [ ] Contingent ______________________ ____-___-______
Name Social Security Number
_______________________________________________________________________
Address
___________________________________________ ________________%
Relationship Share
[ ] Primary [ ] Contingent ______________________ ____-___-______
Name Social Security Number
_______________________________________________________________________
Address
___________________________________________ ________________%
Relationship Share
[ ] Primary [ ] Contingent ______________________ ____-___-______
Name Social Security Number
_______________________________________________________________________
Address
___________________________________________ ________________%
Relationship Share
In the event of my death, the balance in
the account shall be paid to the Primary
Beneficiaries who survive me in equal
shares (or in specified shares, if
indicated). If the Primary or Contingent
Beneficiary box is not checked for the
beneficiary, the beneficiary will be
deemed to be a Primary Beneficiary. If
none of the Primary Beneficiaries
survive me, the balance in the account
shall be paid to the Contingent
Beneficiaries who survive me in equal
shares (or in the specified shares, if
indicated).
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12. Consent of Spouse
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I consent to the above Beneficiary Designation.
Signature of Spouse: ___________________________________________ Date:
_______________ (Note: Consent of the Participant's Spouse may be required
in a community property or marital property state to effectively designate
a beneficiary other than or in addition to the Participant's Spouse.)
Disclaimer for Community and Property States: The Participant's Spouse may
have a property interest in the account and the right to dispose of the
interest by will. Therefore, the custodian disclaims any warranty as to the
effectiveness of the Participant's beneficiary designation or as to the
ownership of the account after the death of the Participants' Spouse. For
additional information, please consult your legal advisor.
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13. Signatures
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Under penalties of perjury, I certify that the above information (including
my social security number) is correct. I hereby agree to participate in the
Individual Retirement Custodial Account offered by the Custodian. I
acknowledge receipt of a copy of the plan document under which this Xxxx
Individual Retirement Account is established, a copy of this Adoption
Agreement, and a copy of the Disclosure Statement with respect to this Xxxx
Individual Retirement Account. I direct that all benefits upon my death be
paid as indicated above. In the event that this is a rollover contribution,
the undersigned hereby irrevocably elects, pursuant to the requirements of
Section 1.402(a)(5)-1T of the XXX regulations, to treat this contribution
as a rollover contribution.
Participant Signature: ____________________________________________________
Date: ______________
Signature of Custodian: ___________________________________________________
Date: ______________
