IDA Training Log
IDA Account Close-Out Form
IDA Participant Information
|Organization Name: | | | |
|Date: | | |Participant SSN: | |
| | | |
|Participant Name (Last, First): | |
|Financial Institution Name: | |
| | | |
|Savings Account # | | |Match # | |
| | | | | |
| Reason for Closing: | | | | |
| | Graduated | | Terminated - Non compliance | |
| | Voluntary | | Moved out of State | |
| | Dormant/Abandoned | | | Other ____________________ |
| | | | | |
| Additional Notes: |(Please give detailed explanation) | |
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| | | |I, the undersigned IDA account holder, understand that | |
| | | |this withdrawal effectively closes my IDA Account. | |
| | | |______ Initials | |
| | | | | |
| | | |I, the undersigned IDA account holder, understand that | |
| | | |once I close my account, I am excluded from future | |
| | | |participation in Indiana’s IDA Program. | |
| | | |______ Initials | |
| | | | | |
| Amount Returned to Participant: | | | | |
| |Savings: | | | | |
| |Interest: | | | | |
| |Total Returned: | | | | |
| | | | | | |
| Amount Returned to IHCDA: | | | |
| |State: | | | | | |
| | | | | | | |
| |Federal: | | | | | |
| | | | | | | |
| |Total: | | | | | |
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|Participant Signature | |Date |
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| | | |
|IDA Administrator | |Date |
I, the undersigned IDA account holder, understand that closing my IDA account in this manner forfeits my ability to use any remaining matching funds that may have accumulated during my participation in Indiana’s IDA Program. My savings will be returned to me and any remaining matching funds will be returned to IHCDA.
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