SEPP Sample Form for Plan Documentation

This is a sample of a form that could be used for documemtation and to request an initial distribution under IRC Section 72(t). While there is no requirement that a SEPP Plan be reduced to writing, it will help to document the assumptions, calculations and distributions. It was designed to comply with Revenue Ruling 2002-62.

This form was designed to indicate some of the possibilities and we make no warranties or representations regarding the suitability or usability of this sample form in your distribution planning.

Check with the financial institution where you have your account - they should have a form with their approved list ofptions.

Account Owner's Name: __________________________________

Account Owner's Date of Birth: ___/___/______

Beneficiary's Date of Birth: ___/___/______ (for Joint calculations)

1)	Calculation Method
		Life Expectancy: _______.__ Years
		Amortization Method
		Annuitization Method - Mortality Table: ____________
	To comply with RR 2002-62, all calculations should be done using the Annuity 2003 table.
2)	Life Expectancy [LE]
		Single Life Expectancy
		Joint Life Expectancy
3)	Interest Rate: ________% for Amortization and Annuitization Methods.
	To comply with RR 2002-62, the maximum rate should be limited to 120% of the Federal Mid-Term AFR for either of the two months immediately preceeding the month that the first payment is to be made. Once established, it should remain fixed.
4)	Annual Recalculation
		Annual Recalculation of Age, Interest Rate and Balance
		No Recalculation
5)	Account: Balance: $_____________ as of ___/___/______ To comply with RR 2002-62, the initial valuation date should probably be the December 31 of the prior year, or on a date within a reasonable period before that year's distribution.
6)	Calculated Annual Payment: Amount: $____________
7)	Recalculation Date: If selected, Annual Recalculation will be determined as of _____ (Month) and _____ (Day) of each year based on the account balance as of 12/31 of the previous year.

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