Citibank IRA Contribution Form

Enclosed please find your requested Individual Retirement Account (IRA) documents for you to complete and

return. Unless you have already converted to simplified banking, by returning the enclosed documents for the

below-listed actions, you will initiate Early Access to convert any eligible deposit and investment accounts you

currently own to simplified banking.

• Opening a new Traditional or Roth IRA.

• Opening a new Certificate of Deposit (CD) account or Insured Money Market Account (IMMA) within an

existing IRA.

If you choose not to proceed at this time, you can convert later by initiating Early Access or you will be converted

by Citibank pursuant to a separate notice in 2024.

Please note: Uniform Transfers to Minors Act (UTMA) / Uniform Gifts to Minors Act (UGMA) accounts, and

Special Title accounts, and their beneficial owners, are ineligible for Early Access.

About simplified banking:

• Citibank’s simplified banking will transform the way you bank. We are enhancing the customer experience,

which includes changing how you receive benefits and features, automatically linking eligible accounts you

own, simplifying our checking products and providing you with different opportunities to waive Monthly

Service Fees.

As part of these changes, we are eliminating Account Packages.

If you meet the qualifying

Balance Ranges, you will enjoy the benefits of the Citi Priority, Citigold® and Citigold® Private Client

Relationship Tiers.

Please note that IRAs do not have Monthly Services Fees and will be unaffected by this particular change.

IRA account customers with no other deposit accounts are in the Citibank Account Package.

• You can convert to simplified banking before your conversion date by initiating Early Access. Before you

choose Early Access or engage in activities that will initiate Early Access, learn more about how simplified

banking will impact you and your accounts by speaking to a banker or by viewing your simplified banking

snapshot and Early Access at citi.com/earlyaccess. Please note, once you convert to simplified banking, your

accounts cannot return to an Account Package.

Here’s how conversion works:

• Customers in the Citibank Account Package will immediately join Relationship Tiers if they have at least

$30,000 in combined average monthly balances (CAMB) in the month prior to conversion.

• Customers with accounts in the Citi Priority, Citigold and Citigold Private Client Account Packages on their

conversion date will remain in Relationship Tiers by the same name unless they meet a higher CAMB Balance

Range in the month prior to conversion.

• Customers may be converted to a Legacy Relationship as defined in the Citi Consumer Deposit Account

Agreement (“CMA”). You will be notified after conversion if a Legacy Relationship applies to your accounts.”

For more information

The Client Manual — Consumer Accounts and Marketplace Addendum (“CMMA”) applies to existing non-

retirement Citibank accounts that have not been converted to simplified banking. The Consumer Deposit

Account Agreement (“CMA”) applies to accounts in simplified banking. Terms, conditions and fees for accounts,

products, programs and services are subject to change. Agreements are subject to change without notice unless

required by law and amendments will be made available to you. You can obtain copies of the current CMA and

CMMA online at citi.com/accountagreementsandnotices and copies of the CMA in Citibank branches.

If you have any questions, please do not hesitate to contact your local branch or call 1-800-321-CITI (For TTY:

We accept 711 or other Relay Service).

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What you need to know

Please review the information below before you complete this form.

Please ensure you supply the following along with your completed application:

• Please complete all sections marked as “Must Complete” to avoid delays with your contribution.

• To fund the account, either attach a check made payable to Citibank, N.A. or provide instructions

to debit your Citibank checking or savings account.

Please read and keep all documents below with your important records:

• If enrolled under a Traditional IRA Plan, please visit: citi.com/TraditionalIRAplan; for Roth IRA visit: citi.com/RothIRAplan

• Addendum to the Citibank Retirement Plan Documents and Coverdell Education Savings Account-

Cost of Living Adjustment (COLA) Information, please visit:

citi.com/AddendumCOLAInformation

• Consumer Deposit Account Agreement, please visit: citi.com/ConsumerDepositAccountAgreement

• Privacy Notice, please visit: citi.com/ConsumerPrivacyNotice

When requesting a direct rollover of funds from another institution please remember to:

• Attach a completed Citibank Transfer and Direct Rollover form

• Attach your distribution confirmation statement or your most recent account statement

• Please include a check payable to Citibank N.A. as Successor Custodian

When requesting a conversion or recharacterization of a contribution from an existing Citibank Traditional IRA or SEP-IRA,

please remember to:

• Attach a completed Citibank IRA and Roth IRA Withdrawal and Tax Withholding Election Form.

• A Roth IRA conversion cannot be undone or recharacterized.

Please Note:

• You cannot make a contribution to an inherited IRA.

• This form cannot be used to facilitate a trustee-to-trustee transfer.

• To request a trustee-to-trustee transfer please use the Citibank Transfer and Direct Rollover form

and provide your most recent account statement copy.

• Under current law, you may make only one rollover from an IRA to another (or the same) IRA in any 12-month period,

regardless of the number of IRAs you own.

Return completed form(s) to a Citibank branch or mail form(s) to:

Retirement Plan Services

P.O. Box 769001

San Antonio, TX 78245-9951

For overnight delivery, send to:

Retirement Plan Services

100 Citibank Drive

San Antonio, TX 78245

If you have any questions

Call Retirement Plan Services at 1-800-695-5911.

* For TTY: we accept 711 or other Relay Service. Representatives are available to

assist you Monday through Friday 8:00 a.m. – 10:00 p.m. Eastern Time, and Saturday 9:00 a.m. – 5:30 p.m. Eastern Time.

*To ensure quality service, calls are recorded

BRANCH USE ONLY. The below information is required when this form is submitted by branch personnel.

Representative Name: ______________________________________________________

SOEID:

__________________________________

Date: ____________________________________

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Citibank IRA Contribution Form

This form is only to be used by customers who are making an additional contribution to an existing Citibank Traditional IRA, Roth IRA,

or SEP-IRA. If you wish to open a Traditional IRA, Roth IRA, or SEP-IRA, please complete the corresponding Citibank IRA Application.

If you are making a recharacterization or conversion contribution, please attach

a completed Citibank IRA or Roth IRA

Withdrawal and Tax Withholding Election Form. Please Note, you cannot make a contribution to an inherited IRA.

You must complete Sections 1-5 to avoid delays with your application process.

PLEASE PRINT OR TYPE (For use by existing retirement plan customers only)

1. Plan Owner Information (Must Complete)

First Name: __________________________________Middle: ______________________________ Last Name: ____________________________________

Address

 Check here if this is a new address

Street Address:

_________________________________________________________________________________ Apt. Number: _____________________

City: _____________________________________State: _____________________________ Zip: ________________ Country: ________________________

Social Security Number __________________________

Phone Number (Please at least one)

Daytime Phone: _______________________________________ Evening Phone: ______________________________________________

By providing a phone number, you agree that we or our service providers can contact you at that number by text message, artificial

voice, pre-recorded or autodialed calls. Your phone plan charges may apply.

2. Contribution Type and Total Amount of Your Contribution (Must Complete)

Contributions received between January 1st and the tax filing due date (without extensions) for the prior year’s return must be

specifically identified as a prior year contribution if that is your intention. If the contribution is not specifically designated as being for

the prior tax year, it will be treated as a current year contribution. Contributions which exceed the maximum allowable for the prior year

will be applied as a current year contribution. Contribution information is reported to the IRS.

Be sure to read the Citibank Traditional IRA Plan Documents to determine the deductibility of your Traditional IRA contribution. Be sure

to read the Citibank Roth IRA Plan Documents to determine your eligibility to contribute to a Roth IRA.

Please indicate the plan type to which you are making your contribution and the tax year and amount of your contribution.

Remember that the plan must already be in existence.

Contribution For Tax year

_______________

 IRA $ ______________________  SEP $ __________________

 Rollover IRA $ _____________  Roth IRA $ _____________

Contribution For Tax year _______________

 IRA $ ______________________  SEP $ __________________

 Rollover IRA $ _____________  Roth IRA $ _____________

 Rollover Contribution (please see footnote #1 for more details)

Please Note: Under current law, you may make only one rollover from an IRA to another (or the same) IRA in any 12-month period,

regardless of the number of IRAs you own. If you have completed an IRA-to-IRA rollover in the preceding 12 months you may not

complete another nontaxable rollover at this time. Rollovers from employer plans, and direct trustee-to-trustee transfers are

not subject to this limitation. For additional information, see https://www.irs.gov/retirement-plans/plan-participant-employee/

rollovers-of-retirement-plan-and-ira-distributions

 Direct Rollover  Late Direct Rollover  60 Day Rollover  Late 60 Day Rollover

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Rollover Contribution (continued)

Plan type from which the distribution was made:

 Traditional IRA  Roth IRA  401K  ESOP  Profit Sharing Plan  Other: ______________________________

Original Distribution Amount $ ________________

Rollover Contribution Amount $ _______________

Original date that funds were distributed __________________________________

Date funds were received __________________________________________________

 Recharacterization Contribution (please see footnote #2 for more details)

Amount $ _____________________________________

 From a Traditional IRA  From a Roth IRA  From a SEP-IRA

 Conversion Contribution (To a Roth IRA only, please see footnote #3 for more details)

Amount $ ______________________________________

 Repayment of Coronavirus-Related Distribution (“CRD”) (please see footnote #4 for more details)

Amount $ _____________________________________

 Repayment of CRD taken from a Citibank IRA

 Repayment of CRD taken from an employer plan or non-Citi IRA

 Repayment of Qualified Birth or Adoption Distribution (please see footnote #5 for more details)

Amount $ _____________________________________

 Repayment of birth or adoption distribution taken from a Citibank IRA

 Repayment of birth or adoption distribution taken from an employer plan or non-Citi IRA

Footnotes:

The rollover must occur within 60 days of the date you received the funds. Please include a copy of your distribution confirmation statement if you

are establishing a plan with funds you previously withdrew from an IRA, Roth IRA, Qualified Plan, or SEP-IRA. For more information please review

https://www.irs.gov/retirement-plans/accepting-late-rollover-contributions

If you are recharacterizing a contribution from an existing Citibank Traditional IRA, Roth IRA, or SEP-IRA, please also attach a completed

Citibank IRA and Roth IRA Withdrawal and Tax Withholding Election Form. A Roth IRA conversion made on or after January 1, 2018, cannot be

re-characterized. For details, see “Recharacterizations” in Publication 590-A, Contributions to Individual Retirement Arrangements (IRAs)

https://www.irs.gov/forms-pubs/about-publication-590-a

If you are converting a contribution from an existing Citibank Traditional IRA or SEP - IRA, please also attach a completed Citibank IRA or Roth IRA

Withdrawal and Tax Withholding Election Form.

For more information about Coronavirus-Related Distributions and repayments,

visit https://www.irs.gov/newsroom/coronavirus-related-relief-for-retirement-plans-and-iras-questions-and-answers

Beginning in 2020, an IRA owner or a participant in a workplace defined contribution plan can withdraw up to $5,000 for the birth or adoption of a

child without incurring the usual 10% additional tax on early distributions. The distribution must be made within one year after the child is born or

the adoption is finalized. The IRA owner or plan participant may generally recontribute any portion of the distribution as a rollover contribution to an

eligible retirement plan, including an IRA, by December 31, 2025 for distributions received on or before December 29, 2022, and within 3 years of the

date the distribution was received for distributions received after December 29, 2022.

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3. Contribution Method (Must Complete)

a.  Check attached (Check must be made payable to Citibank, N.A. For direct rollovers, the check should be payable to Citibank,

N.A. as Successor Custodian)

b.  Debit from a Citibank checking or savings account:

 One time debit

Please deduct $ ___________________________from my Citibank checking or savings account # _____________________________

 Monthly debit (contributions are for the current year only and will be credited to an IRA plan)

Please deduct $ ___________________________from my Citibank checking or savings account # _____________________________

on the _____________________ day of each month, beginning with the month of ________________________ .

4. Investment Options (Must Complete)

Refer to your Citibank IRA Plan Documents. Citibank can hold contribution funds uninvested or deposit funds in a Citibank Insured Money

Market (“IMMA”) account if you do not provide clear written directions by the time Citibank receives the funds or in order to process

certain transactions including requests from you, a beneficiary, a local state or federal governmental entity or other authorized party.

Certificates of Deposit (“CD”) and IMMA accounts will receive the interest rate in effect when Citibank receives the funds. Please refer

to the IRA account Product section of the IRA Account Supplement for details. For current Annual Percentage Yields and interest rates

for CD and IMMA accounts in a Citibank IRA, visit citi.com, speak to a banker in a Citibank branch, or call Retirement Plan Services.

Contribution amounts you list here cannot exceed the total contribution amount indicated in Section 2 and Section 3.

 Certificate(s) of Deposit (“CD”)

Term ______________________ Term ________________________ Term ________________________

Amount $ _________________ Amount $ ___________________ Amount $ ___________________

(minimum deposit $250) (minimum deposit $250) (minimum deposit $250)

 Insured Money Market (“IMMA”) account

Account Number: ___________________________ Amount $ _______________________

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5. Acceptance (please read this section carefully, and sign and date below)

By signing below, I authorize, certify and/or acknowledge that:

• I have read and understand all the information provided and as outlined in this form.

• For contributions to a new deposit account: I have read and agree to the terms of the Consumer Deposit Account Agreement (“CMA”),

which applies to accounts in simplified banking. Unless I have already converted to simplified banking, by choosing to proceed with

the request on this form, Early Access will be initiated to convert any Citibank accounts I own to simplified banking. When converted to

simplified banking, I may be converted to a “Legacy Relationship” and may become eligible for a “Relationship Tier” as defined in the CMA.

• If I was converted to a Legacy Relationship when converted to simplified banking, I have now either converted to a “Family Link” or

have opted out of the Legacy Relationship.

• I have received the updated applicable Traditional/ Roth Individual Retirement Custodial Account Agreement (“Custodial

Agreement”) and the applicable Traditional/Roth IRA Disclosure Statement that includes the IRA Financial Disclosure (“Disclosure

Statement”), that amends and restates the previously provided Custodial Agreement and Disclosure Statement applicable to my

Citibank Traditional/Roth IRA.

• Citibank will send written notice confirming contributions to my Citibank Traditional/Roth IRA. Any discrepancies or errors in any

notice about my Citibank Traditional/Roth IRA must be reported to Citibank within 60 days of the notice date.

• Any election to have a contribution treated as a Rollover cannot be revoked.

• The contribution is made for the tax year(s) indicated.

• For contributions to a new deposit account: I have received, read, and agree to the terms of the IRA Account Supplement to the

Consumer Deposit Account Agreement (“IRA Account Supplement”) applicable to the deposit account type(s) selected.

• Insured Money Market (“IMMA”) accounts and Certificate of Deposit (“CD”) accounts are deposit products offered by Citibank, N.A.

Member FDIC.

• Citibank can hold contribution funds uninvested or deposit funds in a Citibank IMMA account if I do not provide clear written

directions by the time Citibank receives the funds or in order to process certain transactions including requests from me, a

beneficiary, a local state or federal governmental entity or other authorized party.

• IMMA accounts and CDs will receive the interest rate in effect when Citibank receives the funds. Please refer to the IRA account

Products section of the IRA Account Supplement for details. For current Annual Percentage Yields and interest rates for IMMA

accounts and CD accounts in a Citibank IRA, visit citi.com, speak to a banker at a Citibank branch, or call Retirement Plan Services.

• For contributions to a new deposit account: During this application process, Citibank may verify my identity using commercially

available databases containing information from public records, other financial institutions and consumer reporting agencies.

This form must be received within 90 days of the date of your signature. If the form is received after 90 days of your dated signature,

Citibank will request a new form to be completed.

► Signature: ____________________________________________________________________________ ► Date: ______________________________

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