THE BERWYN FUNDS
XXXX Individual Retirement Account
THE BERWYN FUNDS
XXXX Individual Retirement Account
Application Instructions 1
Xxxx XXX Disclosure Statement 2
Custodial Account Agreement 6
Application, Adoption Agreement
& Beneficiary Designation 11
Transfer Authorization Form 13
Rollover/Conversion Certification Form 15
APPLICATION INSTRUCTIONS
DO NOT USE THIS FORM FOR EDUCATION, SEP, SIMPLE OR TRADITIONAL IRAs.
1 HOW TO COMPLETE THE ENCLOSED FORMS:
If you are opening a Xxxx XXX which will not contain contributions
that have been transferred from another Xxxx XXX or a Traditional IRA:
* To establish a Xxxx XXX, please complete the "Application, Adoption
Agreement and Beneficiary Designation" (Application). Please note
that the Applicant's name must be that of an individual, not a
business.
* If you are opening a Xxxx XXX for your spouse who is unemployed or
earns less than you earn, a separate Application must be completed by
your spouse.
* The maximum allowable contribution to your Xxxx XXX is the lesser of
(a) $2,000 or (b) 100% of your compensation or earnings from self-
employment. If your spouse is not employed or earns less than you
earn, your spouse may also contribute to a Xxxx XXX. The maximum
contribution to your spouse's Xxxx XXX is the lesser of (a) $2,000, or
(b) the combined compensation of both spouses, minus the dollar amount
of the IRA contribution made by the compensated (or more highly
compensated) spouse. The total contribution to each individual's IRAs
(deductible, non-deductible and Xxxx) combined cannot exceed these
limits. There is a phase-out of eligibility to make a Xxxx XXX
contribution if your adjusted gross income (AGI) is between $95,000
and $110,000 for single filers, between $150,000 and $160,000 for
married joint filers and between $0 and $10,000 for a married separate
filer.
* The minimum initial investment per Fund is $1,000. If you are
dividing your contribution between Xxxx IRAs for yourself and your
spouse, the amounts invested per Fund in each account will be combined
for the purpose of satisfying the minimum initial investment.
Prospectuses for the Funds may be obtained from the Fund at 1-800-992-
6757. Please be sure to read the prospectus carefully before
investing.
* Please be sure to read carefully the "Terms and Conditions of the
Xxxx XXX Adoption Agreement" in Section 5 of the Application. There
is a $10.00 annual custodial maintenance fee on each account in the
Fund.
* Please make checks payable to THE BERWYN FUNDS. If you are dividing
your contribution between yourself and your spouse's Xxxx XXX, only
one check, with instructions on how to allocate the contribution
between accounts, needs to be included with both Applications.
If you are opening a Xxxx XXX which will contain contributions which
have been transferred from another Xxxx XXX or a Traditional IRA:
* Please read and follow the general instructions above for
establishing a Xxxx XXX. Be sure to note on the Application that your
contribution is a transfer, a rollover from another Xxxx XXX, or a
Conversion Xxxx XXX.
* You may not establish a Conversion Xxxx XXX in any tax year in which
your adjusted gross income exceeds $100,000, or if you are married and
filing separately.
* To transfer the distribution from your current Xxxx XXX directly
from that plan to your BERWYN FUNDS Xxxx XXX, please complete a
"Transfer Authorization Form".
* To certify that the contribution you are making to the Xxxx XXX is a
rollover from a Xxxx XXX or a converted Traditional IRA, please
complete the "Rollover/Conversion Certification Form." Rollovers and
Conversions must be completed within 60 calendar days of the date you
receive the distribution.
2 MAIL THE COMPLETED APPLICATION AND CHECK (IF APPLICABLE) TO:
First Class Mail: Overnight
Express:
THE BERWYN FUNDS THE BERWYN FUNDS
Attn: THE BERWYN FUNDS IRA Attn: THE BERWYN
FUNDS IRA
PO Box 8987 000 Xxxxxxxx Xxxx
Xxxxx 000
Xxxxxxxxxx, XX 00000-0000 Xxxxxxxxxx, XX
00000-3710
0-000-000-0000
XXXX INDIVIDUAL RETIREMENT ACCOUNT DISCLOSURE STATEMENT
The following information is the disclosure statement required by
Federal Tax regulations. You should read this disclosure statement,
the Custodial Account Agreement, and the prospectuses for the Funds in
which your BERWYN FUNDS Xxxx Individual Retirement Account (Xxxx XXX)
contributions will be invested.
REVOCATION OF YOUR XXXX XXX
You have the right to revoke your BERWYN FUNDS Xxxx XXX and receive
the entire amount of your initial contribution by notifying PNC Bank,
National Association, the Custodian of your BERWYN FUNDS Xxxx XXX, in
writing within seven (7) days of establishment of your Xxxx XXX. If
you revoke your Xxxx XXX within seven days, you are entitled to a
return of the entire amount paid by you, without adjustment for such
items as sales commission, administrative expenses, or fluctuations in
market value. If you decide to revoke your Xxxx XXX, notice should be
delivered or mailed to:
First Class Mail: Overnight
Express:
PNC Bank, National Association PNC Bank,
National Association
c/o PFPC Inc. c/o PFPC Inc.
Attn: THE BERWYN FUNDS Xxxx XXX Attn: THE BERWYN
FUNDS Xxxx XXX
PO Box 8987 000 Xxxxxxxx Xxxx
Xxxxx 000
Xxxxxxxxxx, XX 00000-0000 Xxxxxxxxxx, XX
00000-3710
0-000-000-0000
This notice should be signed by you and include the following:
1. The date;
2. A statement that you elect to revoke your
BERWYN FUNDS Xxxx XXX;
3. Your BERWYN FUNDS Xxxx XXX account number;
4. The date your BERWYN FUNDS Xxxx XXX was
established;
5. Your signature and your printed or typed name.
Mailed notice will be deemed given on the date that it is postmarked,
if it is deposited in the United States mail, first class postage
prepaid and properly addressed. This means that if you mail your
notice it must be postmarked on or before the seventh day after your
BERWYN FUNDS Xxxx XXX was opened. A revoked Xxxx XXX will be reported
to the Internal Revenue Service and the Depositor on Forms 1099-R and
5498.
YOUR XXXX INDIVIDUAL RETIREMENT ACCOUNT
You have opened a BERWYN FUNDS Xxxx Individual Retirement Account
which is an account for the exclusive benefit of you and your
beneficiaries, created by a written instrument (the Custodial Account
Agreement). The following requirements apply to your BERWYN FUNDS
Xxxx XXX:
1. Contributions, transfers and rollovers may be
made only in "cash" by check, draft, or other form acceptable to the
Custodian;
2. The Custodian must be a bank;
3. No part may be invested in life insurance;
4. Your interest must be nonforfeitable;
5. The assets of the custodial account may not be
mixed with other property except in a common investment fund;
6. There is no age limit on contributions as long
as you have earned income;
7. Your adjusted gross income must be within the
eligibility limits (discussed under "Contributions" below); and
8. There are no mandatory withdrawals during your
lifetime.
CONTRIBUTIONS
The maximum allowable contribution to your Xxxx XXX is the lesser of
(a) $2,000 or (b) 100% of your compensation or earnings from self-
employment. If your spouse is not employed or earns less than you
earn, your spouse may also contribute to a Xxxx XXX. The maximum
contribution to your spouse's Xxxx XXX is the lesser of (a) $2,000, or
(b) the combined compensation of both spouses, minus the dollar amount
of the IRA contribution made by the compensated (or more highly
compensated) spouse. The total contribution to each individual's IRAs
(deductible, non-deductible and Xxxx) combined cannot exceed these
limits.
Contributions can be made to a Xxxx XXX past age 70 -1/2 as long as
the above requirements of earned income are met.
There is a phase-out of eligibility to make a Xxxx XXX contribution if
your adjusted gross income (AGI) is between certain levels.
For a single depositor, the $2,000 maximum annual contribution is
phased out to zero between AGI of $95,000 and $110,000; for a married
depositor who files jointly, between AGI of $150,000 and $160,000; and
for a married depositor who files separately, between $0 and $10,000.
Single filers with AGI above $110,000, joint filers with AGI above
$160,000 and married separate filers with AGI above $10,000 in 1998
may not contribute to a Xxxx XXX.
Conversion IRA Rollovers
You may only convert a Traditional IRA into a Conversion Xxxx XXX if
your AGI (single or joint) does not exceed $100,000 and you do not
file married and separately. If a distribution is converted from a
Traditional IRA, i.e. deposited to your BERWYN FUNDS Xxxx XXX within
60 calendar days of receipt, the amount converted will be taxed as
ordinary income, except that the amount of any distribution from the
Traditional IRA which represents non-deductible contributions is not
taxed. The IRS enforces the 60-day time limit strictly. The 10%
penalty for distributions under age 59-1/2 will not apply to the
amount converted if held in your Conversion Xxxx XXX for at least five
years and certain other criteria are met. See the section on Taxation
of Distributions below. The rules regarding conversions to Xxxx IRAs
are complex and you should consult your tax advisor prior to rolling
over all or any part of a distribution.
EXCESS CONTRIBUTIONS
Amounts contributed to your BERWYN FUNDS Xxxx XXX in excess of the
allowable limit will be subject to a non-deductible excise tax of 6%
for each year until the excess is used up as an allowable contribution
(in a subsequent year) or returned to you. A distribution of excess
contributions may be subject to the 10% excise tax on early
distributions discussed below. The 6% excise tax will not apply if the
excess contribution and earnings applicable to it are distributed by
the due date for your Federal Income Tax Return, including extensions.
INCOME TAX DEDUCTION
Your contribution is not deductible on your Federal Income Tax Return.
TAXATION OF DISTRIBUTIONS
Contributory Xxxx IRAs
Any distribution, or portion of any distribution, which consists of
the return of contributions you made to your BERWYN FUNDS Xxxx XXX is
not subject to federal income tax. For federal income tax purposes,
contributions are presumed to be withdrawn first. The earnings on
your contributions will not be subject to federal income tax when
withdrawn if the assets being withdrawn have been in your Xxxx XXX for
at least five (5) years, and any one of the following criteria is also
met:
1. you are over the age of 59-1/2, or
2. used to purchase a first home, up to $10,000, or
3. made because you became disabled, or
4. due to your death.
All distributions made prior to the five-year holding period,
regardless of the reason, are subject to ordinary income tax on the
earnings plus a 10% penalty tax on early distributions. Exceptions to
the 10% penalty are described below in the section on Early
Distributions under Penalty Tax on Certain Transactions.
Rollovers from one Xxxx XXX to another Xxxx XXX are permitted within
the 60 calendar day period after receipt. The amount rolled over
within 60 days will not be taxable. The IRS enforces the 60-day time
limit strictly. Rollovers from a Xxxx XXX to a Regular IRA are not
permitted.
Conversion Xxxx IRAs
The five-year holding period applies separately to each year's
converted IRA funds. For example, a conversion in 1998 and a second
conversion in 2000 would have two different five-year periods, one
ending in 2003 and one ending in 2005, with non-taxable distributions
being available if the other criteria above are met beginning in the
sixth year after the conversion. IRS penalties, in addition to the
10% premature distribution penalty which applies if you are under age
59-1/2, may apply if you withdraw from a Conversion Xxxx XXX prior to
the five-year period.
Distributions under $10 will not be reported to you on IRS Form 1099-R
as allowed under IRS regulations. However, you must still report
these distributions to the IRS on IRS Form 1040 as well as other forms
which may be required to properly file your tax return.
PENALTY TAX ON CERTAIN TRANSACTIONS
Excess Contributions
If you make an excess contribution to your Xxxx XXX and it is not
corrected on a timely basis, an excise tax of 6% is imposed on the
excess amount. This tax will apply each year to any part or all of
the excess which remains in your account.
Early Distributions
All distributions made prior to the five-year holding period,
regardless of the reason, are subject to ordinary income tax on the
earnings plus the 10% penalty tax on early distributions. The
distribution is subject to the penalty tax unless the distribution is
the result of one of the following exceptions:
1. you are over age 59-1/2, or
2. due to death, or
3. made because you became disabled, or
4. used specifically for deductible medical expenses which exceed 7.5%
of your adjusted gross income, or
5. used for health insurance cost due to your unemployment, or
6. used for higher education defined in section 529(e)(3) of the
Internal Revenue Code, or
7. used to cover expenses of first time home purchase up to $10,000,
or
8. part of a scheduled series of substantially equal payments over
your life, or over the joint life expectancy of you and a beneficiary.
If you request a distribution in the form of a series of substantially
equal payments, and you modify the payments before 5 years have
elapsed and before attaining age 59-1/2, the penalty tax will apply
retroactively to the year payments began through the year of such
modification.
The 10% penalty tax is in addition to any federal income tax that is
owed at distribution. For more information on the 10% penalty tax and
the exceptions listed above, consult IRS Publication 590.
Required Distributions
You are not required to take distributions from your Xxxx XXX during
your lifetime.
ADDITIONAL INFORMATION ON DISTRIBUTIONS
A Xxxx XXX distribution request form is available from the Custodian,
and should be obtained and used to request any distribution from your
Xxxx XXX.
PROHIBITED TRANSACTIONS
If you or your beneficiary engage in any prohibited transaction (such
as any sale, exchange, borrowing, or leasing of any property between
you and your Xxxx XXX; or any other interference with the independent
status of the account), the account will lose its exemption from tax
and be treated as having been distributed to you. The value of the
earnings on your account will be includable in your gross income. If
you are under age 59-1/2, you would also be subject to the 10% penalty
tax on early distributions.
If you or your beneficiary use (pledge) all or any part of your Xxxx
XXX as security for a loan, then the portion so pledged will be
treated as if distributed to you, and will be taxable to you as a
nonqualified distribution, and subject to a 10% penalty tax on the
taxable portion of such distribution if you have not attained age 59-
1/2 during the year which you make such a pledge.
INCOME TAX WITHHOLDING
The Custodian is required to withhold income tax from any distribution
from your Xxxx XXX to you at the rate of 10% unless you choose not to
have tax withheld. You may elect out of withholding by advising the
Custodian in writing, prior to the distribution, that you do not want
tax withheld from the distribution. This election may be made on IRS
Form W-4P, or any other form acceptable to the Custodian. If you do
not elect out of tax withholding, you may direct the Custodian to
withhold an additional amount of tax in excess of 10%, but not more
than 90%.
ADDITIONAL INFORMATION
For more detailed information, you may obtain Publication 590,
Individual Retirement Arrangements (IRAs) from any district office of
the Internal Revenue Service or by calling 0-000-XXX-XXXX.
Any Xxxx XXX transaction may have tax consequences; consult your tax
adviser to obtain information about the tax consequences in connection
with your particular circumstances.
INFORMATION ABOUT YOUR INVESTMENTS
A mutual fund investment involves investment risks, including possible
loss of principal. In addition, growth in the value of your account
is neither guaranteed nor projected due to the characteristics of a
mutual fund investment. Detailed information about the shares of each
mutual fund available for investment by your BERWYN FUNDS Xxxx XXX
must be furnished to you in the form of a prospectus. The method for
computing and allocating annual earnings is set forth in the
prospectus. (See prospectus section entitled "DIVIDENDS.") If you
made an initial contribution of $1,000 on the first day of a calendar
year and no further investment during that year, your contribution
would also be subject to certain costs and expenses which would reduce
any yield you might obtain from your investment. (See the prospectus
section entitled "EXPENSE TABLE" and the sections referred to
therein.) For further information regarding expenses, earnings, and
distributions, see the fund's financial statements, prospectus and/or
statement of additional information.
FEES AND CHARGES
The charges in connection with your BERWYN FUNDS Xxxx XXX are set
forth in the Application. The Custodian may also charge a service fee
in connection with any distribution from your Xxxx XXX.
IRS APPROVED FORM
Your BERWYN FUNDS Xxxx XXX is the Internal Revenue Service's model
custodial account contained in IRS Form 5305-RA. Certain additions
have been added in Article IX of the form. By following this form,
your BERWYN FUNDS Xxxx XXX meets the requirements of the Internal
Revenue Code. However, the IRS has not endorsed the merits of the
investments allowed under the Xxxx XXX. This form cannot be used with
Education, SEP, SIMPLE or Traditional IRAs.
CUSTODIAL ACCOUNT AGREEMENT
(Under section 408A of the Internal Revenue Code - Form 5305-RA
(January 1998))
The depositor whose name appears in the accompanying Application is
establishing a Xxxx individual retirement account (Xxxx XXX) under
section 408A to provide for his or her retirement and for the support
of his or her beneficiaries after death.
The custodian, PNC Bank, National Association (PNC Bank), has given
the depositor the disclosure statement required under Regulations
section 1.408-6.
The depositor and the custodian make the following agreement:
ARTICLE I
1. If this Xxxx XXX is not designated as a Xxxx Conversion IRA, then,
except in the case of a rollover contribution described in section
408A(e), the custodian will accept only cash contributions and only up
to a maximum amount of $2,000 for any tax year of the depositor.
2. If this Xxxx XXX is designated as a Xxxx Conversion IRA, no
contributions other than IRA Conversion Contributions made during the
same tax year will be accepted.
ARTICLE II
The $2,000 limit described in Article I is gradually reduced to $0
between certain levels of adjusted gross income (AGI). For a single
depositor, the $2,000 annual contribution is phased out between AGI of
$95,000 and $110,000; for a married depositor who files jointly,
between AGI of $150,000 and $160,000; and for a married depositor who
files separately, between $0 and $10,000. In the case of a
conversion, the custodian will not accept IRA Conversion Contributions
in a tax year if the depositor's AGI for that tax year exceeds
$100,000 or if the depositor is married and files a separate return.
Adjusted gross income is defined in section 408A(c)(3) and does not
include IRA Conversion Contributions.
ARTICLE III
The depositor's interest in the balance in the custodial account is
nonforfeitable.
ARTICLE IV
1. No part of the custodial 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 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 grantor's surviving spouse is not
the sole beneficiary, the entire remaining interest will, at the
election of the depositor or, if the depositor has not so elected, at
the election of the beneficiary or beneficiaries, either:
(a) Be distributed by December 31 of the year containing the fifth
anniversary of the depositor's death, or
(b) Be distributed over the life expectancy of the designated
beneficiary starting no later than December 31 of the year following
the year of the depositor's death.
If distributions do not begin by the date described in
(b), distribution method (a) will apply.
2. In the case of distribution method 1.(b) above, to determine the
minimum annual payment for each year, divide the grantor's entire
interest in the trust as of the close of business on December 31 of
the preceding year by the life expectancy of the designated
beneficiary using the attained age of the designated beneficiary as of
the beneficiary's birthday in the year distributions are required to
commence and subtract 1 for each subsequent year.
3. If the depositor's spouse is the sole beneficiary on the
depositor's date of death, such spouse will then be treated as the
depositor.
ARTICLE VI
1. The depositor agrees to provide the custodian with information
necessary for the custodian to prepare any reports required under
sections 408(i) and 408A(d)(3)(E), Regulations sections 1.408-5 and
1.408-6, and under guidance published by the Internal Revenue Service.
2. The custodian agrees to submit reports to the Internal Revenue
Service and the depositor as prescribed by the Internal Revenue
Service.
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 that are not consistent with
section 408A, the related regulations, and other published guidance
will be invalid.
ARTICLE VIII
This agreement will be amended from time to time to comply with the
provisions of the Code, related regulations, and other published
guidance. Other amendments may be made with the consent of the
depositor and the custodian.
ARTICLE IX
1. All funds in the custodial account (including earnings)
shall be invested in shares of beneficial interest of any one or more
of the regulated investment companies managed by the company listed on
the Application Form ("company") contained in this package or any of
its subsidiaries or affiliates, and which have been designated by such
company as eligible for investment under this custodial account, which
investment companies shall be collectively referred to as "the Funds"
and which shares shall be collectively referred to as "Fund Shares".
Fund Shares shall be purchased at the public offering value for Fund
Shares next to be determined after receipt of the contribution by the
custodian or its agent.
2. The shareholder of record of all Fund Shares shall be
the custodian or its nominee.
3. The depositor shall, from time to time, direct the
custodian to invest the funds of his/her custodian account in Fund
Shares. Any funds which are not directed as to investment will be
returned to the depositor without being deemed to have been
contributed to his/her custodial account. The depositor shall be the
beneficial owner of all Fund Shares held in the custodial account, and
the custodian shall not vote any such shares except upon written
direction of the depositor.
4. The custodian agrees to forward, or to cause to be
forwarded, to every depositor the then-current prospectus(es) of the
Funds, as applicable, which have been designated by the company as
eligible for investment under the custodial account and selected by
the depositor for such investment, and all notices, proxies and
related proxy soliciting materials applicable to said Fund Shares
received by it.
5. Each depositor shall have the right by written notice
to the custodian to designate or to change a beneficiary to receive
any benefit to which such depositor may be entitled in the event of
his/her death prior to the complete distribution of such benefit. If
no such designation is in effect on the depositor's death, or if the
designated beneficiary has predeceased the depositor, the beneficiary
shall be the depositor's estate.
6. (a) The custodian shall have the right to receive
rollover and conversion contributions as allowed under IRS Code
Section 408A, however it is the depositor's responsibility to ensure
that such rollovers and conversions are eligible to be contributed to
this Xxxx XXX. The custodian reserves the right to refuse to accept
any property which is not in the form of cash.
(b) The custodian, upon written direction of the
depositor and after submission to the custodian of such documents as
it may reasonably require, shall transfer the assets held under this
Agreement (reduced by any amounts referred to in paragraph 8 of this
Article IX) to a successor Xxxx Individual Retirement Account or
directly to the depositor.
Any amounts received or transferred by the custodian under this
paragraph 6 shall be accompanied by such records and other documents
as the custodian deems necessary to establish the nature, value and
extent of the assets and of the various interests therein.
7. Without in any way limiting the foregoing, the
depositor hereby irrevocably delegates to the custodian the right and
power to amend at any time and from time to time the terms and
provisions of this Agreement and hereby consents to such amendments,
provided they shall comply with all applicable provisions of the Code,
the Treasury regulations thereunder and with any other governmental
law, regulation or ruling. Any such amendments shall be effective
when the notice of such amendments is mailed to the address of the
depositor indicated by the custodian's records.
8. Any income taxes or other taxes of any kind whatsoever
levied or assessed upon or in respect of the assets of the custodial
account or the income arising therefrom, any transfer taxes incurred,
all other administrative expenses incurred, all other administrative
expenses incurred by the custodian in the performance of its duties
including fees for legal services rendered to the custodian, and the
custodian's compensation may be paid by the depositor and, unless so
paid within such time period as the custodian may establish, shall be
paid from the depositor's custodial account. The custodian reserves
the right to change or adjust its compensation upon 30 days advance
notice to the depositor.
9. The benefits provided hereunder shall not be subject to
alienation, assignment, garnishment, attachment, execution or levy of
any kind, and any attempt to cause such benefits to be so subjected
shall not be recognized, except to such extent as may be required by
law.
10. The custodian may rely upon any statement by the
depositor when taking any action or determining any fact or question
which may arise under this Custodial Agreement. The depositor hereby
agrees that the custodian will not be liable for any loss or expense
resulting from any action taken or determination made in reliance on
such statement. The depositor assumes sole responsibility for
assuring that contributions to the custodial account satisfy the
limits specified in the appropriate provisions of the Code.
11. The custodian may resign at any time upon 30 days
written notice to the depositor and may be removed by the depositor at
any time upon 30 days written notice to the custodian. Upon the
resignation or removal of the custodian, a successor custodian shall
be appointed within 30 days of such resignation notice and in the
absence of such appointment, the custodian shall appoint a successor
unless the Agreement be sooner terminated. Any successor custodian
shall be a bank (as defined in section 408(n) of the Code) or such
other person found qualified to act as a custodian under an individual
account plan by the Secretary of the Treasury or his delegate. The
appointment of a successor custodian shall be effective upon receipt
by the custodian of such successor's written acceptance which shall be
submitted to the custodian and the depositor. Within 30 days of the
effective date of a successor custodian's appointment, the custodian
shall transfer and deliver to the successor custodian applicable
account records and assets of the custodial account (reduced by any
unpaid amounts referred to in paragraph 8 of this Article IX). The
successor custodian shall be subject to the provisions of this
Agreement (or any successor thereto) on the effective date of its
appointment.
12. The custodian shall, from time to time, in accordance
with instructions in writing from the depositor, make distributions
out of the custodial account to the depositor in the manner and
amounts as may be specified in such instructions (reduced by any
amounts referred to in Article IX, paragraph 8). A Xxxx XXX
Withdrawal Authorization form is available from the custodian, and
should be obtained and used to request any distribution from your Xxxx
XXX. The custodian assumes (and shall have) no responsibility to make
any distribution to the depositor (or the depositor's beneficiary if
the depositor is deceased) unless and until such written instructions
specify the occasion for such distribution and the elected manner of
distribution. Prior to making any such distribution from the
custodial account, the custodian shall be furnished with any and all
applications, certificates, tax waivers, signature guarantees, and
other documents (including proof of any legal representative's
authority) deemed necessary or advisable by the custodian, but the
custodian shall not be liable for complying with written instructions
which appear on their face to be genuine, or for refusing to comply if
not satisfied such instructions are genuine, and assumes no duty of
further inquiry. Upon receipt of proper written instructions as
required above, the custodian shall cause the assets of the custodial
account to be distributed in cash and/or in kind, as specified in such
written instructions.
13. No distributions are required to be taken from the Xxxx
XXX during the lifetime of the depositor. If the depositor desires to
take distributions from the Xxxx XXX, such distributions of the assets
of the custodial account shall be made as the depositor shall elect by
written instructions to the custodian. The recalculation of life
expectancy of the depositor and/or the depositor's spouse beneficiary
may be made only at the written election of the depositor. The
recalculation of life expectancy of the spouse beneficiary shall only
be made at the written election of the surviving spouse beneficiary.
14. The custodian is authorized to hire agents (including
any transfer agent for Fund Shares) to perform certain duties
thereunder.
15. This Agreement shall terminate coincident with the
complete distribution of the assets of the depositor's account.
16. All notices to be given by the custodian to the
depositor shall be deemed to have been given when mailed to the
address of the depositor indicated by the custodian's records.
17. The custodian shall not be responsible for any losses,
penalties or other consequences to the depositor or any other person
arising out of the making of, or the failure to make, any contribution
or withdrawal.
18. In addition to the reports required by paragraph (2) of
Article VI, the custodian shall periodically cause to be mailed to the
depositor in respect of each such period an account of all
transactions affecting the custodial account during such period and a
statement showing the custodial account as of the end of such period.
If, within 60 days after such mailing, the depositor has not given the
custodian written notice of any exception or objection thereto, the
periodic accounting shall be deemed to have been approved and, in such
case or upon the written approval of the depositor, the custodian
shall be released, relieved and discharged with respect to all matters
and statements set forth in such accounting as though the account had
been settled by judgment or decree of a court of competent
jurisdiction.
19. In performing the duties conferred upon the custodian
by the depositor hereunder, the custodian shall act as the agent of
the depositor. The parties do not intend to confer any fiduciary
duties on the custodian and none shall be implied. The custodian
shall not be liable (and does not assume any responsibility) for the
collection of contributions, the propriety of any contribution under
this Agreement, the selection of any Fund Shares for this custodial
account, or the purpose or propriety of any distribution made, which
matters are the sole responsibility of the depositor or the
depositor's beneficiary, as the case may be.
20. The custodian shall be responsible solely for the
performance of those duties expressly assigned to it in this Agreement
and by operation of law. In determining the taxable amount of a
distribution, the depositor shall rely only on his or her Federal tax
records, and the custodian shall withhold Federal income tax from any
distribution from the custodial account as if the total amount of the
distribution is includable in the depositor's income.
21. Except to the extent superseded by Federal law, this
Agreement shall be governed by, and construed, administered and
enforced according to, the laws of the Commonwealth of Pennsylvania,
and all contributions shall be deemed made in Pennsylvania.
GENERAL INSTRUCTIONS
(Section references are to the Internal Revenue Code unless otherwise
noted.)
Purpose of Form
Form 5305-RA is a model custodial account agreement that meets the
requirements of section 408A and has been automatically approved by
the IRS. A Xxxx individual retirement account (Xxxx XXX) is
established after the form is fully executed by both the individual
(depositor) and the custodian. This account must be created in the
United States for the exclusive benefit of the depositor or his or her
beneficiaries.
Do not file Form 5305-RA with the IRS. Instead, keep it for your
records.
Unlike contributions to traditional individual retirement
arrangements, contributions to a Xxxx XXX are not deductible from the
grantor's gross income; and distributions after 5 years that are made
when the grantor is 59 1/2 years of age or older or on account of
death, disability, or the purchase of a home by a first-time homebuyer
(limited to $10,000), are not includible in gross income. For more
information on Xxxx IRAs, including the required disclosure the
depositor can get from the custodian, get Pub. 590, Individual
Retirement Arrangements (IRAs).
This Xxxx XXX can be used by a depositor to hold: (1) IRA Conversion
Contributions, amounts rolled over or transferred from another Xxxx
XXX, and annual cash contributions of up to $2,000 from the depositor;
or (2) if designated as a Xxxx Conversion IRA (by checking the box on
the application), only IRA Conversion Contributions for the same tax
year.
To simplify the identification of funds distributed from Xxxx IRAs,
depositors are encouraged to maintain IRA Conversion Contributions for
each tax year in a separate Xxxx XXX.
Definitions
Xxxx Conversion IRA. A Xxxx Conversion IRA is a Xxxx XXX that accepts
only IRA Conversion Contributions made during the same tax year.
IRA Conversion Contributions. IRA Conversion Contributions are
amounts rolled over, transferred, or considered transferred from a
nonRoth IRA to a Xxxx XXX. A nonRoth IRA is an individual retirement
account or annuity described in section 408(a) or 408(b), other than a
Xxxx XXX.
Custodian. The custodian must be a bank or savings and loan
association, as defined in section 408(n), or any person who has the
approval of the IRS to act as custodian.
Depositor. The depositor is the person who establishes the custodial
account.
SPECIFIC INSTRUCTIONS
Article I. The depositor may be subject to a 6 percent tax on excess
contributions if (1) contributions to other individual retirement
arrangements of the depositor have been made for the same tax year,
(2) the depositor's adjusted gross income exceeds the applicable
limits in Article II for the tax year, or (3) the depositor's and
spouse's compensation does not exceed the amount contributed for them
for the tax year. The depositor should see the disclosure statement
or Pub. 590 for more information.
Article IX. - Article IX and any that follow it may incorporate
additional provisions that are agreed to by the depositor and
custodian to complete the agreement. They may include, for example,
definitions, investment powers, voting rights, exculpatory provisions,
amendment and termination, removal of the custodian, custodian's fees,
state law requirements, beginning date of distributions, accepting
only cash, treatment of excess contributions, prohibited transactions
with the depositor, etc. Use additional pages if necessary and attach
them to this form.
Note: Form 5305-RA may be reproduced and reduced in size.
THE BERWYN FUNDS Xxxx XXX APPLICATION
c/o PFPC Inc. PO Box 8987 ADOPTION AGREEMENT &
Wilmington DE 19899-8987 BENEFICIARY DESIGNATION
Page 1 of 2
For assistance in completing this form please
call 0-000-000-0000.
th pages must be completed.
1. Please tell us about yourself: This information is required in
order to establish your account.
-
First Middle Last Name
Social Security Number
______________________________________________________________________
________________/______/______
Street
Date of Birth
______________________________________________________________________
______________(____)__________
City State
Zip Code Telephone
2. Please tell us about your contribution in A. Please indicate the
dollar amount or percentage of your contribution you wish to invest in
each Fund in section B. The initial investment must be at least
$1,000 in each fund.
A. TYPE OF XXXX: (Specify Contributory or Conversion and the type of
contribution)
CONTRIBUTORY XXXX
CONTRIBUTION - CURRENT YEAR $____________. PRIOR
YEAR $__________. (No more than $2,000 per year)
ROLLOVER - This contribution is a ROLLOVER from a Contributory XXXX
XXX which has been completed within 60 days of receipt of the funds.
Tax year original Xxxx Established: _______________.
TRANSFER OF ASSETS - This contribution is a TRANSFER OF ASSETS from
another Contributory XXXX XXX. I have attached a completed
"Transfer of Assets" form. Tax Year Original Xxxx Established
________________.
CONVERSION XXXX: My income for the current tax year is under
$100,000 and I am not married filing separately.
ROLLOVER - This contribution is a CONVERSION from a
TRADITIONAL IRA which has been completed within 60 days of receipt of
the funds. I realize I must pay ordinary income taxes on the amount
being converted from the Traditional IRA to the CONVERSION XXXX XXX.
TRANSFER OF ASSETS - This contribution is a Transfer
of Assets from a CONVERSION XXXX XXX. Date of conversion:_________.
B. INVESTMENT: (Contributions will be considered CURRENT year if not
designated above.)
THE BERWYN FUND $ OR
% ________________
BERWYN INCOME FUND $ OR
% ________________
$
OR % ________________
$
OR % ________________
3. BENEFICIARY DESIGNATION
Complete this section to designate Primary and Contingent
Beneficiary(ies) to receive, in the event of your death, any benefits
which may be payable under your Xxxx XXX. A beneficiary must survive
you to receive anything. If your Primary Beneficiary(ies) do not
survive you, your Contingent Beneficiary(ies) will receive the funds.
If more than one person is named and no percentage is indicated, a
joint tenancy with the right of survivorship will be deemed to have
been created. If the beneficiary is a trust, please indicate the date
of the trust and the trustee(s) name. You may change your
beneficiaries at any time by giving written notice to the custodian.
Participant's Designation: In the event of my death, I hereby
designate the following individuals as the Primary and Contingent
Beneficiary(ies) to receive all benefits that may become due and
payable under my BERWYN FUNDS Xxxx XXX.
Consent of Participant's Spouse: Spousal consent is required in
community property and marital property states where a Xxxx XXX
Depositor wishes to name a beneficiary other than, or in addition to,
the spouse. Spouses of Participants who reside in community property
or marital property states (AZ, CA, ID, LA, NV, NM, TX, WA, WI) must
sign the consent below.
I hereby consent to and join in the designation of beneficiary(ies)
below. I give to the Depositor any interest I have in the funds
deposited in this account.
______________________________________________________________________
_____________________
Signature of Participant's Spouse (if applicable)
Date
(over)
THE BERWYN FUNDS Xxxx XXX APPLICATION
Page 2 of 2 ADOPTION AGREEMENT &
BENEFICIARY DESIGNATION
Primary Beneficiary(ies): Please check here if you have attached a
separate sheet with additional Primary Beneficiaries. Sign and date
the sheet.
____________________________________________________
____________________________________________________
Name % of Distribution
Name % of Distribution
____________________________________________________
____________________________________________________
Street Street
____________________________________________________
____________________________________________________
City State Zip Code
City State Zip Code
____________________________________________________
____________________________________________________
Birth Date Relationship Birth Date
Relationship
___________________________________(______)__________
_________________________________(_______)__________
Social Security Number Telephone
Social Security Number Telephone
Contingent Beneficiary(ies): Please check here if you have attached
a separate sheet with additional Contingent Beneficiaries. Sign and
date the sheet.
____________________________________________________
____________________________________________________
Name % of Distribution
Name % of Distribution
____________________________________________________
____________________________________________________
Street Street
____________________________________________________
____________________________________________________
City State Zip Code
City State Zip Code
____________________________________________________
____________________________________________________
Birth Date Relationship Birth Date
Relationship
___________________________________(______)__________
__________________________________(______)__________
Social Security Number Telephone Social
Security Number Telephone
TERMS AND CONDITIONS OF THE Xxxx XXX ADOPTION AGREEMENT
Please sign and date this Xxxx XXX Application Agreement & Beneficiary
Designation form "Application". You, the Depositor, acknowledge that
you have received and read the current Prospectus for each Fund which
you have designated for investment.
All subsequent contributions will be invested as indicated by you in
the "Investment" section of this form. All dividends and
distributions from the Fund shares held in your Account will be
reinvested in shares of the Fund from which received. The custodian,
upon written instructions from you, may exchange any BERWYN FUNDS
shares for any other BERWYN FUNDS shares in accordance with the then
current prospectus.
Custodial Fees: $10.00 annual maintenance fee per account. The annual
maintenance fee may be paid by the Depositor in addition to the
maximum annual contribution to his or her Xxxx XXX. If the fee is not
included, the custodian will deduct the fee from the Account at year-
end or at the time the Account is closed.
The custodian reserves the right to change the custodian fee, but will
give at least 30 days written notice to the Depositor of any fee
changes. The custodian will keep those records, identify and file
returns and provide other information concerning your Account as
required of custodians by the Internal Revenue Code and any
Regulations issued or forms adopted by the Treasury Department of the
United States.
I (the Depositor) hereby establish a Xxxx XXX under the terms and
conditions contained in the accompanying Custodial Account Agreement,
which is incorporated herein by reference. The combined instrument is
hereinafter referred to as the "Agreement." This Xxxx XXX becomes
effective upon written acceptance of this Application by the
custodian, PNC Bank, National Association, which written acceptance
shall consist of a confirmation of transaction statement issued by the
custodian. The Depositor understands and agrees that the custodian is
not responsible for any assets until received. The Depositor
understands the eligibility requirements for contributing to a Xxxx
XXX and assumes all responsibility for each years' contribution,
ensuring that the contributions are within the limits set forth in
section 408A and any tax consequences of any type of contribution
(rollover, conversion or contributory) or distribution from the Xxxx
XXX.
I (the Depositor) certify under penalties of perjury that my Social
Security Number is true, correct and complete and that this number is
my Taxpayer Identification Number.
Owner's
Signature_____________________________________________________________
___________ Date________________________
Acceptance by custodian shall consist of a confirmation of transaction
statement issued by the custodian: PNC Bank, National Association, C/O
PFPC Inc., 000 Xxxxxxxx Xxxxxxx, Xxxxxxxxxx, XX 00000.
FOR DEALER USE ONLY
_____________________________________________________________________
__________________________________________________________________
Broker/Dealer Number
Representative's Number
THE BERWYN FUNDS Transfer of Assets
Page 1 of 2 Xxxx XXX
Instructions for
completing this form are provided on page 2
1. Please tell us about yourself:
/ / .
Name (Exactly as it appears on your current retirement account)
Date of Birth
- - .
Street
Social Security Number
( ) .
City State
Zip Code Daytime Telephone
2. Please tell us where to invest. Complete items A, B and C.
A. I am opening a new account(s) and have attached the C.
These are funds from CONVERSION XXXX XXX.
required application or documents.
Date Converted: ________________
Deposit the proceeds into my existing Xxxx XXX.
These are Xxxx Contribution monies.
B. Please purchase into the following funds or account:.
Tax Year of First Contribution: ______________.
THE BERWYN FUND $ OR
% ________________
BERWYN INCOME FUND $ OR
% ________________
$
OR % ________________
$
OR % ________________
3. Please tell us about your current plan and authorize the transfer
from your current custodian.
* Check with your current custodian for the correct address and if
they need a signature guarantee to avoid delays.
* Attach a copy of a current statement if possible.
TRANSFER OF ASSETS CAN ONLY OCCUR BETWEEN XXXX IRAs.
________________________________________________________
Name of current Custodian or Agent
________________________________________________________
Address of current Custodian or Agent
________________________________________________________
City State Zip Code
( ) Telephone
Number of Custodian
I authorize the transfer of assets as noted above to my BERWYN FUNDS
Xxxx XXX and authorize THE BERWYN FUNDS and PNC Bank, N.A. to process
this request on my behalf. I understand it is my responsibility to
assure the prompt transfer of assets by the current custodian. I have
read and understand all information in the instructions.
________________________________________________________
Signature of Xxxx XXX Depositor (Required) Date
________________________________________________________
Signature Guarantee Stamp and Signature
(If required by your current custodian or transfer agent)
Please transfer the following investments to PNC Bank, N.A. as
custodian for THE BERWYN FUNDS Xxxx XXX.
For Certificate of Deposits Immediately At Maturity __________
Date
1._______________________________________________________
Fund Name or Type of Investment to be transferred
_________________________________________________________
Account Number for Investment 1
Entire Account Partial $____________________
2 _______________________________________________________
Fund Name or Type of Investment to be transferred
_________________________________________________________
Account Number for Investment 1
Entire Account Partial $____________________
TO BE COMPLETED BY PNC BANK CUSTODIAN ONLY
ISSUE CHECK PAYABLE TO:
THE BERWYN FUNDS FBO:_________________________________
Account No:_______________________________________________
SSN: ____________________________________________________
(over)
THE BERWYN FUNDS Transfer of Assets
Page 2 of 2 Xxxx XXX
INSTRUCTIONS TO THE SHAREHOLDER (PLEASE READ CAREFULLY):
This form will be used by BERWYN FUNDS to initiate a transfer of
assets on your behalf from an existing Xxxx XXX as designated on this
form to your Xxxx XXX plan at BERWYN FUNDS. Please remember that a
TRANSFER OF ASSETS can only occur between two XXXX IRAs. If you are
requesting a ROLLOVER or a Conversion IRA, please complete the
ROLLOVER CERTIFICATION FORM. For certificate of deposits please
indicate if you wish to have the funds transferred immediately, which
may incur a redemption penalty if they have not matured, or at
maturity. We can not accept requests to transfer assets from
certificates more than 60 days prior to their maturity. When
completed, please return the signed form, a copy of your current
custodian's statement, and the appropriate new account application for
your Xxxx XXX if required to:
First Class Mail Overnight Mail:
THE BERWYN FUNDS THE BERWYN FUNDS
C/O PFPC Inc. C/O PFPC Inc.
PO Box 8987 000 Xxxxxxxx Xxxx Xxxxx 000
Xxxxxxxxxx XX 00000-8987 Wilmington DE 19809-3710
Insufficient information or incorrect forms will result in delays in
processing your instructions. If you need assistance in completing
this form please contact our Customer Service Representatives at 1-
000-000-0000. We would be happy to help you. If you need additional
forms please call 0-000-000-0000.
INSTRUCTIONS TO RESIGNING CUSTODIAN/TRANSFER AGENT:
Please liquidate the Depositor's account(s) ONLY IF THEY ARE XXXX
IRAs, as specified in section 3. Issue a check payable as indicated
in section 3 and mail along with any other instructions to:
First Class Mail Overnight Mail:
THE BERWYN FUNDS THE BERWYN FUNDS
C/O PFPC Inc. C/O PFPC Inc.
PO Box 8987 000 Xxxxxxxx Xxxx Xxxxx 000
Xxxxxxxxxx XX 00000-8987 Wilmington DE 19809-3710
ACCEPTANCE BY PNC BANK, NATIONAL ASSOCIATION AS CUSTODIAN:
PNC Bank, National Association (PNC Bank, N.A.), accepts its
appointment as custodian of the above referenced Xxxx XXX account and
has established a Xxxx XXX as indicated by the shareholder on the
front of this form under the relevant IRS guidelines for Xxxx IRAs
under the shareholder's name in BERWYN FUNDS. BERWYN FUNDS and PNC
Bank, N.A., as custodian, cannot accept assets other than cash. Upon
receipt of the check, the proceeds will be credited to the named
shareholder's account.
Accepted by PNC Bank, N.A., as custodian for THE BERWYN FUNDS.
__________________________________________________
_________________________
Authorized Representative of PNC Bank, N.A.
Date
THE BERWYN FUNDS ROLLOVER/CONVERSION
CERTIFICATION FORM
Use this form to certify a rollover distribution from your current
Xxxx XXX or eligible conversion distribution from a Traditional IRA to
your BERWYN FUNDS Xxxx XXX. You must complete the rollover within 60
calendar days of your receipt of that distribution.
- - .
First Middle Last Name
Social Security Number
/ .
Street
Date of Birth
( ) .
City State
Zip Code Telephone
TYPE OF ROLLOVER CONTRIBUTION (Please check one)
Xxxx XXX Rollover - A distribution from another Xxxx XXX which
is being rolled over into your BERWYN FUNDS Xxxx XXX within 60 days of
receipt. Note that 365 days must have passed since you last received a
rollover distribution from the distributing Xxxx XXX.
Traditional IRA Conversion Distribution - A distribution from
a regular (traditional) IRA which is being converted and/or rolled
over into your BERWYN FUNDS Conversion Xxxx XXX within 60 days of
receipt. Ordinary income taxes must be paid on the distribution in
the year of the distribution, with the exception that income taxes in
respect to distributions taken in 1998 must be paid over four years.
Qualified Domestic Relations Order Distribution.
CERTIFICATION
I certify that the contribution described above is an eligible Xxxx
XXX rollover/conversion contribution and that I am rolling over this
contribution within 60 calendar days of my receipt of that
distribution. I understand that this rollover is irrevocable and
involves important tax considerations. Other tax considerations may
also apply.
I agree that I am solely responsible for all tax consequences of this
rollover contribution. I also agree that the Xxxx XXX custodian shall
have no responsibility for any tax consequences.
I have read and understand and agree to be legally bound by the terms
of this form. I also understand that the Xxxx XXX custodian will rely
on this form when accepting my rollover/conversion contribution. I
understand I am not eligible for a Conversion if my adjusted gross
income exceeds $100,000 or I am married and filing separately. I
understand that this rollover/conversion is irrevocable and may not be
reversed in the future. I also understand that I am responsible for
the movement of the rollover/conversion to my successor Xxxx XXX, and
that PNC Bank, National Association and PFPC Inc. have no duty to
enforce the collection of any assets to be rolled over to my BERWYN
FUNDS Xxxx XXX.
______________________________________________________________________
___________________________
Depositor's Signature
Date
THE BERWYN FUNDS Xxxx XXX
c/o PFPC Retirement Plan Services WITHDRAWAL AUTHORIZATION
PO Box 8987 Wilmington DE 19899-8987 AND INSTRUCTIONS FOR
DISTRIBUTION
Page 1 of 2
For assistance in completing this form please call our customer
service at 0-000-000-0000.
Please tell us about yourself:
NAME:_________________________________________________________________
______________________________________
(PLEASE PRINT FULL NAME)
SOCIAL SECURITY NUMBER:_________-_______-_________
DATE OF BIRTH _________/_________/_________
mm dd yy
ADDRESS:______________________________________________________________
______________________________________
STREET ADDRESS
CITY STATE
ZIP
FUND : ______________________________________________ ACCOUNT
NUMBER: ______________________________________
ACCOUNT TYPE: CONTRIBUTORY 1st Tax Year of Contributions _________
CONVERSION Year of Conversion _________
Reason For Distribution - Check the box that applies in both sections
A and B.
A. Over five year holding period OR Five year
holding period not reached
B. Under age 59 1/2
1st Time Home Purchase
Age 59 1/2 or older Divorce or
Legal Separation
Disability Death
The proper documentation must be received or attached for each
distribution type before the request will be processed. All legal
documents must be a certified copy; and signature guarantees are
required for the Xxxx XXX owner/beneficiary or spouse.
Payout Method
Partial Withdrawal / Amount:_______________________________________
DOLLARS / SHARES (CIRCLE ONE)
Total Distribution of Account
Mail to my address currently on file.
Mail to the following address:
Purchase funds into my existing non-retirement
mutual fund account:
_______________________________________________________
Account Number _________________________________________
_______________________________________________________
Fund___________________________________________________
Financial Institution Name:_________________________________
NEW ACCOUNT; check here and attach completed application to
Account Number:_________________________________________
purchase funds into a new mutual fund account.
(to be used if check going to another Financial
Institution)
(over)
WITHHOLDING ELECTION (Form W-4P OMB#1545-0415)
THE BERWYN FUNDS XXXX XXX
Page 2 of 2 WITHDRAWAL AUTHORIZATION
AND INSTRUCTIONS FOR DISTRIBUTION
Federal income tax will be withheld from payments from Xxxx IRAs
unless you elect otherwise. You can use Form W-4P, or a substitute
form such as this one, to instruct the fund to withhold no tax from
your Xxxx XXX payment or to revoke this election. Generally, non-
periodic payments must have tax withheld at a rate of 10%. You can
elect to have no income tax withheld from a nonperiodic payment by
filing Form W-4P or this substitute with the fund and check the
appropriate box on the form. Your election will remain in effect for
any subsequent distributions unless you change or revoke your election
by completing a new W-4P or substitute form, and submit it to the
fund.
Number of allowances on which withholding is to be
computed ________.
_____ I elect not to have federal income tax withheld from my
distribution.
_____ I elect to have federal income tax withheld from my
distribution. If you want a percentage exceeding the current rate,
please indicate
the percentage _________% (not more than 90%).
_____ I want the following additional amount withheld from each
distribution $__________.
Caution: Remember you are liable for the payment of Federal income tax
on the taxable amount of your distribution(s) and there are penalties
for not paying enough tax during the year, either through withholding
or estimated tax payments.
SIGNATURE
I certify that I am the Depositor authorized to make these elections
and that all information provided is true and accurate. I further
certify that no tax or legal advice has been given to me by the
custodian, THE BERWYN FUNDS, or any agent of either of them, and that
all decisions regarding the elections made on this form are my own.
The custodian is hereby authorized and directed to distribute funds
from my account in the manner requested . The custodian may
conclusively rely on this certification and authorization without
further investigation or inquiry. I expressly assume responsibility
for any adverse consequences which may arise from the Election(s) and
agree that the custodian, THE BERWYN FUNDS, and their agents shall in
no way be responsible, and shall be indemnified and held harmless, for
any tax, legal or other consequences of the Election(s) made on this
form. This form MAY ONLY be used for one account. If you have
another account from which you wish to take distributions, please fill
out a separate form.
X________________________________________________________________
Date______________________
Depositor's Signature (or beneficiary's signature if Depositor
is deceased.)
____________________________________________
Signature Guarantee - Medallion Stamp*
12/97
*(The medallion signature guarantee may be executed by xxxxx, broker
dealers, credit unions, national securities exchanges and savings
associations which participate in STAMP, SEMP or NYSE-MSP. A notary
public is not a substitute for a Signature Guarantee. The medallion
signature guarantee stamp must include the words "SIGNATURE
GUARANTEED, MEDALLION GUARANTEED" and otherwise comply with the
medallion program requirements. Please check your fund prospectus or
with your fund as to whether a signature guarantee is required.)
First Class Mail:
Overnight Express:
THE BERWYN FUNDS
THE BERWYN FUNDS
Attn: THE BERWYN FUNDS IRA
Attn: THE BERWYN FUNDS IRA
PO Box 8987
000 Xxxxxxxx Xxxx Xxxxx 000
Xxxxxxxxxx, XX 00000-0000
Xxxxxxxxxx, XX 00000-0000
0-000-000-0000
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