ORP/TSA Distribution/IRA Rollover Form

Lamar University/Lamar Institute of Technology
ORP/TSA Distribution/IRA Rollover Form
With few exceptions, you have the right to request, receive, review and correct information about yourself collected using this form.
__________________________________________________
Name (Print)
________________________________________________
Social Security Number or ID number
__________________________________________________
Current address
________________________________________________
continuation of address
INSTRUCTIONS
This form is for use by current employees over age 70 1/2 (ORP accounts) or over age 59 1/2 (TSA accounts) and former
employees whose accounts are still controlled by theTSUS ORP or Supplemental TSA Plan for distributions or rollovers to an IRA.
1. Complete Section A as appropriate, then sign Section B.
2. If rollover to an IRA, Section C must be completed.
3. Return to Human Resources office.
4. If the proposed transaction is acceptable under the applicable plan document, an approved copy will be returned to you. The
surrendering vendor may require that you submit an approved copy with your Social Security Number on it to them along with their
required form(s). The Human Resources office will also complete and sign the employer approval section of any required vendor
forms that are acceptably worded.
A. DISTRIBUTION OR ROLLOVER INSTRUCTIONS (check all that apply)
____ I authorize a: Full distribution ____ or partial distribution ____of: ORP ____ Supplemental TSA ____ account(s).
____ I authorize a: Full rollover____ or partial rollover ____of: ORP ____ Supplemental TSA ____ account(s).
For full distributions or rollovers, indicate only the contract or account number. For partial distributions or rollovers, also indicate the
dollar amount or percent of total to be transferred. (If the amount or percentage differs from that on the vendor's form, the amount
on the vendor's form will prevail.)
Contract or Account # _______________________________________ _________% or $__________________
For partial distributions or rollovers, you must separately instruct the surrendering vendor which funds or other investments are to be
liquidated and distributed or rolled over. This is normally accomplished on the surrendering vendor's form. Attach a copy of the
completed form to this form .
From:__________________________________________________________________________________________________
Name of surrendering vendor
To:_____________________________________________________________________________________________________
Name and address of receiving IRA sponsor (only needed if rollover to an IRA).
B. EMPLOYEE OR FORMER EMPLOYEE SIGNATURE
I understand that the account(s) I am requesting be distributed or rolled over may be subject to surrender charges, contingent
deferred sales charges or other fees from the surrendering vendor, and is subject to federal taxes and possibly additional taxes. I
authorize the surrendering vendor to liquidate my account if liquidation of investments is necessary. If this pertains to an ORP
account, I certify that I did not transfer directly (as defined in the Texas ORP Law and Regulations) to another Texas public
institution of higher education, or I have provided evidence that I have subsequently had a Severance from Employment as defined
in the plan document. If this is a rollover to an IRA, I have been advised that a rollover is eligible for a trustee to trustee transfer. I
understand that, unless age 70 ½, I cannot become employed in any capacity with the institution before the distribution is effected.
____________________________________________________ ______________________________________________
Employee signature
Date
C. RECEIVING VENDOR INFORMATION (Required only for rollover to an IRA. A representative's signature below certifies that
the account to which the funds are being rolled over is a traditional IRA qualified under the Internal Revenue Code and Regulations.
Other evidence, satisfactory to the institution, of rollover acceptance and verification that the funds are being transferred to a
traditional IRA may be attached in lieu of completing this section.)
______________________________
Signature of Representative
______________________________
Telephone number
_____________________________
Name(print)
_____________________________
Fax number
____________________________________
Company
____________________________________
E-mail address
This application must be approved (in Section D on page 2) before any distribution or
rollover is initiated.
Lamar University/Lamar Institute of Technology
ORP/TSA Distribution/IRA Rollover Form
Page 2 – Approval Signatures
__________________________________________________
Name of former employee (Print)
________________________________________________
Social Security Number or ID number
D. TO BE COMPLETED BY HUMAN RESOURCES OFFICE
1. ____ I have verified that the applicant is not currently employed or scheduled to be employed by the institution.
2. ____ This applicant did not, to the best of our knowledge, transfer directly to another Texas public institution of higher education.
3. ____ This applicant transferred directly to another Texas public institution of higher education and has provided evidence (copy
attached) that a Severance from Employment as defined in the plan document has subsequently occurred.
4. ____ This transfer involves an ORP account, I certify that the above applicant ____ does or ____ does not as of this date have
a vested interest in the state’s matching contribution.
5. ____ This applicant is currently employed but is eligible for distribution because of the attainment of age 70 1/2.
6. ____ This applicant is currently employed but is eligible for TSA distribution because of the attainment of age 59 1/2.
__________________________________________________
Name and title of HR employee reviewing this form
____________________________ ____________________
Signature
Date
This distribution or rollover to an IRA is permissible as of this date under the provisions of the applicable plan document and is
approved.
_______________________
Name
Deputy Plan Administrator___
Title
____________________________ ____________________
Signature
Date
After approval by Deputy Plan Administrator, return an approved copy to the employee or former employee, along with copy(ies) for
the surrendering vendor and the receiving vendor , if any. The Deputy Plan Administrator will sign the employer approval section of
any required vendor forms that are legally acceptable. Note that Texas state agencies are constitutionally unable to indemnify any
vendor or hold any vendor harmless. See Attorney General's Opinion MW-475, available at
http://www.oag.state.tx.us/opinions/op46white/mw-475.htm . If a vendor form incorporates an indemnification or a hold harmless
agreement, that provision should be struck before signing and a copy of the Attorney General's Opinion attached.
Instructions on Employee Status for ORP and TSA plan purposes.
1. An employee does not have a Severance from Employment under the plan documents or the State ORP Law unless one full
calendar month elapses or will elapse without compensation for services rendered during that month being paid or due. (Payment
in lieu of accrued vacation is considered earned before the last day of service, even if paid in the month following separation.)
2. An employee does not have a Severance from Employment if the employee reduces percent of effort and thereby becomes
benefits ineligible but continues to work at the same institution without a full month without service. (This arises from the IRS
definition of Severance from Employment.) Such a situation leaves an employee benefits ineligible for active employee benefits,
possibly eligible for retiree benefits, but not qualified to receive an ORP or TSA distribution.
3. An employee does not have a Severance from Employment under the plan documents and the State ORP Law when a
customary contract period ends before August 31 and there is intent on the part of the institution to offer a new contract effective on
September 1. The employee may irrevocably indicate in writing that (s)he will not accept a new contract in order to become eligible
for distributions.
4. A break in service which qualifies the applicant for TRS Retirement Benefits will also qualify the applicant for distribution of TSA
funds provided the applicant is not reemployed by the institution prior to the distribution being consummated.
Distribution: Prepare a copy with original Lamar approval signature for
(1) surrendering vendor
(2) IRA vendor (if any)
(3) HR Benefits File
(4) Employee
LU_ORP_TSA_Distrib_Aug09