Custom Checkbook IRA Application Please complete this form to initiate your Custom Checkbook IRA services, "*" indicates required fields Step 1 of 2 50% OverviewWelcome to Custom Checkbook IRA! Upon submission of this form, ReSure will initiate the LLC formation process and will provide you with LLC Articles of Organization, LLC EIN, and LLC Operating Agreement. Those will be delivered to you electronically through ReSure's online client portal, along with a link to finalize your SDIRA custody and LLC bank accounts online.Your Personal InformationFirst Name* Last Name* Email* Enter Email Confirm Email Phone*Physical AddressAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country IRA/HSA Account Type*Select the type of IRA/HSA account to be formed Traditional IRA Roth IRA Health Savings Account (HSA) IRA/HSA-LLC Domicile Selection*Please enter the state in which you'd like your IRA-LLC to be established. by selecting from dropdown.AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Payment Authorization, Terms & Conditions* I agree to the terms and conditions, and authorize the credit card charges.By checking this box you authorize ReSure LLC to collect the fees due for Express Checkbook IRA services, including applicable recurring payments. Either party may cancel service at any time, for any reason. Subsequent billings to your card will be halted after cancellation. Fees paid prior to requesting cancellation from ReSure are non-refundable; in the event you no longer desire Solera's custody services it is your responsibility to request cancellation from ReSure prior to any impending billing. ReSure does not and will not monitor the status of your account(s) with Solera. By signing below, you represent and warrant that you have provided, and will provide, ReSure LLC, its management, its representatives, and related persons ("ReSure") complete and accurate information and that ReSure may rely upon such information or any direction you may give to ReSure. You acknowledge and agree that ReSure shall have no duty to monitor your actions regard to your retirement account(s). You acknowledge and agree to the following: ReSure is not acting as investment advisor, plan administrator, trustee, account custodian, or fiduciary to your retirement account(s). ReSure has not performed legal or financial due diligence on Solera National Bank ("Solera")and has advised you of that. ReSure has further advised you that you should perform appropriate due diligence prior to entrusting your funds to Solera. You will be entering into a direct relationship with Solera for IRA custody and LLC banking services; ReSure is not a party to those relationships. ReSure's role is limited to facilitating payment for such IRA custody services in accordance with Solera's and your direction. You hereby agree to indemnify and hold harmless ReSure, it's officers, employees, and any other of its representatives from any and all claims, injuries, damages, losses or suits including attorney fees arising out of or resulting from the acts, errors or omissions of Solera. Any information provided by ReSure is not intended to be a substitute for advice from your accountant, attorney, or tax advisor. It is agreed that ReSure’s responsibility for damages, or claims of damage, arising from any form of action other than gross negligence, shall not exceed the total amount paid for the services invoiced. This shall be the exclusive remedy for such causes of action. Either party may bring no action, regardless of form, arising out of the services provided under this agreement, more than one year after the date of the last service provided under this agreement. Any dispute related to services provided shall be settled by arbitration in Kings County, New York according to the rules of the American Arbitration Association. Arbitration is final and binding on the parties. The parties are waiving their rights to seek remedies in court, including the right to a jury trial. The laws and jurisdiction of the State of New York shall govern any and all matters related to this agreement. By signing this document, you consent to transact business using electronic communications, to receive notices and disclosures electronically, and to utilize electronic signatures in lieu of using paper documents. Any part, provision, representation or warranty of these Terms & Acknowledgements which is prohibited or which is held to be void or unenforceable shall be ineffective to the extent of such prohibition or unenforceability without invalidating the remaining provisions hereof.Custom Checkbook IRA One-Time Set-Up Fee*Please note that these fees are not inclusive of state fees, which will be separately billed based on your domicile selection. Price: Custom Checkbook IRA Recurring Annual Service Fee* Price: Credit Card*Card Details Cardholder Name Digital Signature (First and Last Name)*Your typed name above constitutes a signature. 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