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Get Form 5305-sa (rev. December 1996). Simple Individual Retirement Custodial Account

Ate of birth of participant Address of participant Check if transfer SIMPLE IRA Check if amendment Address or principal place of business of custodian Name of custodian Social security number The participant whose name appears above is establishing a savings incentive match plan for employees of small employers individual retirement account (SIMPLE IRA) under sections 408(a) and 408(p) of the Internal Revenue Code to provide for his or her retirement and for the support of his or her.

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