Form 5305-RB

(Rev. April 2017)

Department of the Treasury 

Internal Revenue Service 

Roth Individual Retirement Annuity Endorsement

(Under section 408A of the Internal Revenue Code) 

Do not file 

with the Internal

Revenue Service 

Name of issuer Check if this endorsement supersedes a prior Roth IRA 

endorsement . . . . . . . . . . . . ▶

This endorsement is made a part of the annuity contract to which it is attached, and the following provisions apply in lieu of any 

provisions in the contract to the contrary. 

The annuitant is establishing a Roth individual retirement annuity (Roth IRA) under section 408A to provide for his or her retirement 

and for the support of his or her beneficiaries after death. 

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 issuer 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 an annuitant 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 annuitant filing jointly, between AGI of $186,000 and $196,000; and for a married annuitant 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 annuitant and his or her 

spouse. 

Article III 

The annuitant’s interest in the contract is nonforfeitable and nontransferable. 

Article IV 

1. The contract does not require fixed contributions. 

2. Any dividends (refund of contributions other than those attributable to excess contributions) arising under the contract will be 

applied (before the close of the calendar year following the year of the dividend) as contributions toward the contract. 

Article V 

1. If the annuitant dies before his or her entire interest in the contract is distributed to him or her and the annuitant’s surviving 

spouse is not the designated beneficiary, the remaining interest in the contract 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 in the contract will be distributed, starting by the end of the calendar year following the year of the 

annuitant’s death, over the designated beneficiary’s remaining life expectancy, or a period no longer than such remaining life 

expectancy, as determined in the year following the death of the annuitant. Life expectancy is determined using the single life table in 

Regulations section 1.401(a)(9)-9. 

(b) The remaining interest in the contract will be distributed by the end of the calendar year containing the fifth anniversary of the 

annuitant’s death. 

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

Article VI 

1. The annuitant agrees to provide the issuer 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 issuer agrees to submit to the IRS and annuitant the reports prescribed by the IRS. 

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, or other published guidance will be 

invalid. 

Cat. No. 25871H Form 5305-RB (Rev. 4-2017) 
Form 5305-RB (Rev. 4-2017) Page 2 

Article VIII 

This endorsement 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 on the contract. 

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. 

General Instructions 

Section references are to the Internal 

Revenue Code unless otherwise noted. 

Purpose of Form 

Form 5305-RB is a model annuity 

endorsement that meets the 

requirements of section 408A. However, 

only Articles I through VIII have been 

reviewed by the IRS. A Roth individual 

retirement annuity (Roth IRA) is 

established after the contract, which 

includes this endorsement, is fully 

executed by both the individual 

(annuitant) and the issuer. To make a 

regular contribution to a Roth IRA for a 

year, the IRA must be established no 

later than the due date (excluding 

extensions) of the individual’s income tax 

return for the year. The contract must be 

for the exclusive benefit of the annuitant 

and his or her beneficiaries.

Do not file Form 5305-RB 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 annuitant’s gross 

income; and distributions after 5 years 

that are made when the annuitant 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 issuer must give 

the annuitant, see Pub. 590-A,

Contributions to Individual Retirement 

Arrangements (IRAs), and Pub. 590-B,

Distributions from Individual Retirement 

Arrangements (IRAs).

Definitions 

Issuer. The issuer is the insurance 

company providing the annuity contract. 

The insurance company may use other 

terms besides “issuer” to refer to itself, 

such as, “company,” “insurer,” or “us.” 

Annuitant. The annuitant is the person 

who establishes the annuity contract. 

The insurance company may use other 

terms besides “annuitant” to refer to the 

person who establishes the annuity 

contract, such as, “owner,” “applicant,” 

“insured,” or “you.” 

Specific Instructions 

Article I. The annuitant may be subject 

to a 6% tax on excess contributions if 

(1) contributions to other individual 

retirement arrangements of the annuitant 

have been made for the same tax year, 

(2) the annuitant’s adjusted gross 

income exceeds the applicable limits in 

Article II for the tax year, or (3) the 

annuitant’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 annuitant’s death. Elections 

made pursuant to this article should be 

reviewed periodically to ensure they 

correspond to the annuitant’s intent. 

Under paragraph 2 of Article V, the 

annuitant’s spouse is treated as the 

owner of the Roth IRA upon the death of 

the annuitant, 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 annuitant and 

issuer to complete the contract. They 

may include, for example, definitions, 

investment powers, voting rights, 

exculpatory provisions, amendment and 

termination, removal of the issuer, 

issuer’s fees, state law requirements, 

beginning date of distributions, 

accepting only cash, treatment of 

excess contributions, prohibited 

transactions with the annuitant, etc. 

Attach additional pages if necessary. 

Form 5305-RB (Rev. 4-2017)