Form 5305-R

(Rev. April 2017)

Department of the Treasury 

Internal Revenue Service 

Roth Individual Retirement Trust Account

(Under section 408A of the Internal Revenue Code) 

Do not file 

with the Internal

Revenue Service 

Name of grantor Date of birth of grantor Account number 

Address of grantor 

Check if amendment . . . ▶

Name of trustee Address or principal place of business of trustee 

The grantor 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 trustee named above has given the grantor the disclosure statement required by Regulations section 1.408-6. 

The grantor has assigned the trust . $ 

The grantor and the trustee 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 trustee 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 grantor and his or her 

spouse.

Article III 

The grantor’s interest in the balance in the trust account is nonforfeitable. 

Article IV 

1. No part of the trust account funds may be invested in life insurance contracts, nor may the assets of the trust 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 trust 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 grantor dies before his or her entire interest is distributed to him or her and the grantor’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 grantor’s death, over 

the designated beneficiary’s remaining life expectancy as determined in the year following the death of the grantor. 

(b) The remaining interest will be distributed by the end of the calendar year containing the fifth anniversary of the grantor’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 grantor’s 

death and subtracting 1 from the divisor for each subsequent year. 

3. If the grantor’s surviving spouse is the designated beneficiary, such spouse will then be treated as the grantor. 

Article VI 

1. The grantor agrees to provide the trustee 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). 

2. The trustee agrees to submit to the IRS and grantor the reports prescribed by the IRS. 

Cat. No. 25093N Form 5305-R (Rev. 4-2017) 
Form 5305-R (Rev. 4-2017) Page 2 

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. 

Grantor’s signature Date 

Trustee’s signature Date 

Witness’ signature Date 

(Use only if signature of the grantor or the trustee is required to be witnessed.) 

General Instructions 

Section references are to the Internal 

Revenue Code unless otherwise noted. 

Purpose of Form 

Form 5305-R is a model trust account 

agreement that meets the requirements 

of section 408A. However, only Articles I 

through VIII have been reviewed by the 

IRS. A Roth individual retirement 

account (Roth IRA) is established after 

the form is fully executed by both the 

individual (grantor) and the trustee. This 

account must be created in the United 

States for the exclusive benefit of the 

grantor and his or her beneficiaries. 

Do not file Form 5305-R with the IRS. 

Instead, keep it with your records. 

Unlike contributions to traditional 

individual retirement arrangements, 

contributions to a Roth IRA are not 

deductible from the grantor’s gross 

income; and distributions after 5 years 

that are made when the grantor is 591/2

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 Roth 

IRAs, including the required disclosures 

the trustee must give the grantor, see 

Pub. 590-A, Contributions to Individual 

Retirement Arrangements (IRAs), and 

Pub. 590-B, Distributions from Individual 

Retirement Arrangements (IRAs).

Definitions 

Trustee. The trustee 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 trustee. 

Grantor. The grantor is the person who 

establishes the trust account. 

Specific Instructions 

Article I. The grantor may be subject to 

a 6% tax on excess contributions if

(1) contributions to other individual 

retirement arrangements of the grantor 

have been made for the same tax year, 

(2) the grantor’s adjusted gross income 

exceeds the applicable limits in Article II 

for the tax year, or (3) the grantor’s and 

spouse’s compensation is less than the 

amount contributed by or on behalf of 

them for the tax year. 

Article V. This article describes how 

distributions will be made from the Roth 

IRA after the grantor’s death. Elections 

made pursuant to this article should be 

reviewed periodically to ensure they 

correspond to the grantor’s intent. Under 

paragraph 3 of Article V, the grantor’s 

spouse is treated as the owner of the 

Roth IRA upon the death of the grantor, 

rather than as the beneficiary. If the 

spouse is to be treated as the 

beneficiary, and not the owner, an 

overriding provision should be added to 

Article IX. 

Article IX. Article IX and any that follow 

it may incorporate additional provisions 

that are agreed to by the grantor and 

trustee to complete the agreement. They 

may include, for example, definitions, 

investment powers, voting rights, 

exculpatory provisions, amendment and 

termination, removal of the trustee, 

trustee’s fees, state law requirements, 

beginning date of distributions, 

accepting only cash, treatment of 

excess contributions, prohibited 

transactions with the grantor, etc. Attach 

additional pages if necessary. 

Form 5305-R (Rev. 4-2017)