TDA Direct Rollover Election Form (code TD22)

TDA DIRECT ROLLOVER ELECTION FORM
FOR WITHDRAWAL/DISTRIBUTION OF ACCUMULATIONS
FROM THE TAX-DEFERRED ANNUITY PROGRAM
INSTRUCTIONS
PLEASE READ CAREFULLY
• This form should only be filed by members who elected #2 or #4 in Part D on their “TDA Withdrawal
Application” (code TD32) or by spouse beneficiaries who elected #2 or #4 on their “TDA Withdrawal
Application for Beneficiaries” (code TD32B).
• Members (and spouse beneficiaries) may directly roll over all or part of their TDA withdrawal into one or more
eligible successor programs (i.e., Individual Retirement Arrangements (IRAs) or 401(k) Plans).
• Please note that TRS’ receipt of this form does not constitute a valid filing unless this form is attached to your
correctly completed “TDA Withdrawal Application” or “TDA Withdrawal Application for Beneficiaries.”
• If your rollover election form is completed correctly, TRS would distribute your Direct Rollover according to
the type of TDA withdrawal you made, as follows:
• For partial withdrawals drawn only from your balance in the Fixed Return Fund: Generally within 15 days of
TRS’ receipt of your withdrawal request.
• For all other withdrawals: Generally within 45 days of TRS’ receipt of your withdrawal request.
• Please visit our website and search for “TDA withdrawals” for more information on timeframes for TDA
withdrawals.
• For your convenience, TRS forms and publications are available on our website. If you require additional
assistance, we encourage you to contact our Member Services Center at 1 (888) 8-NYC-TRS.
You must complete all parts of this form.
In Part A: All information must be provided.
In Part B: You must indicate how you would like the funds that you designated for Direct Rollover to be distributed.
• If you elected #2 in Part D of your “TDA Withdrawal Application” or “TDA Withdrawal Application for
Beneficiaries”: Complete Section 1 and indicate how (in what percentages or amounts) your entire withdrawal
should be distributed. You may directly roll over your withdrawal to a maximum of three eligible successor programs.
• If you elected #4 in Part D of your “TDA Withdrawal Application” or “TDA Withdrawal Application for
Beneficiaries”: Complete Section 2 and indicate how (in what percentages or amounts) the amount you
designated for Direct Rollover should be distributed. You may directly roll over your withdrawal to a maximum of
two eligible successor programs.
If you elect to directly roll over funds to one program, write “100” in the first space provided in the applicable section.
If you elect to directly roll over funds to more than one program:
•Youmaywritethepercentageyouwanteachprogramtoreceive;or
•Ifyouknowtheexactamountthatyouaredirectlyrollingover,youmaywritethedollaramountyouwanteach
programtoreceive;or
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•Ifyoudonotknowtheexactamountthatyouaredirectlyrollingover,youmaywritethedollaramountforone
program (or two, if you have chosen three successor programs in all) and write “the balance” in the dollar box
for the remaining selection.
•IfyouwriteinacombinationofdollaramountsthatdoesnotequaltheamountyoudesignatedforDirect
Rollover on your “TDA Withdrawal Application” or “TDA Withdrawal Application for Beneficiaries,” your forms
would be canceled.
In Part C: You must list the eligible successor program(s) that you want to receive this Direct Rollover and indicate whether
each is an IRA or a 401(k) Plan. The programs you indicate in this part will receive the amounts you indicate in Part B.
In Part D: You must sign and date this form.
GENERAL PROVISIONS
Uponreachingage70½,certainnon-retiredindividualswithTRSaccountsmustreceiveanannualRequiredMinimum
Distribution(RMD)amount.AnyamountrepresentinganRMDwouldnotbeeligibleforrolloverinmostcases.(However,
ifyouaresubjecttoRMDrulesandyoumeetyourrequirementsbyreceivingadistributionfromaSection403(b)Plannot
administered by TRS, the entire TDA withdrawal may be eligible for rollover.)
The minimum amount that TRS will directly roll over to a successor program is $200. (This amount may be greater
dependingonthesuccessorprogram’sminimumrequirements.)
Anypaymentoflessthan$200willbesentdirectlytoyoubutwillnotbesubjectto20%withholding;thisincludesany
payment based on a percentage election made on this form that is calculated to be less than $200.
Other important information about restrictions and tax consequences is detailed on the “TDA Withdrawal
Application” and the “TDA Withdrawal Application for Beneficiaries.”
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TDA DIRECT ROLLOVER ELECTION FORM
FOR WITHDRAWAL/DISTRIBUTION OF ACCUMULATIONS
FROM THE TAX-DEFERRED ANNUITY PROGRAM
Please read the instructions before completing this application.
(NOTE: Please print in black or blue ink, and initial any changes that you make on this application.)
PART A: All information must be provided.
FirstName
MI LastName
PermanentHomeAddress
Apt.No. TRSMembership/Retirement/BeneficiaryNumber
City
State Zip Code
SocialSecurityNumber(last4digitsonly)
XX X X X
Primary Phone Number (Checkone:HomeWorkMobile)
(
)
Alternate Phone Number (Checkone:HomeWorkMobile)
(
)
Please keep your personal information with TRS up to date. We will update our records based on the information you provide above,
so do not enter a temporary address;instead,TRSsuggeststhatyouconsulttheU.S.PostalServiceabouthavingyourmailforwarded
onatemporarybasis.Toregisteranychangestoyourpermanentaddress(and/orphonenumber),pleaseaccessourwebsiteorfilea
“Member’sChangeofAddressForm”(codeDM13)or, if applicable, a “Beneficiary’s Change of Address Form” (code DM14) with TRS.
If you are providing new information above, please indicate the effective date:
PART B: Please complete ONE of the sections below. Check off the box next to the applicable section and write your initials in
thespaceprovided.Ifyouwriteinpercentages,thetotalmustequal100%;otherwise,yourformwouldbecanceled.If
youwriteindollaramounts,thetotalmustequaltheamountyoudesignatedforDirectRolloveronyour“TDAWithdrawal
Application”or“TDAWithdrawalApplicationforBeneficiaries”;otherwise,yourformwouldbecanceled.
____
Section 1: If you elected #2 in Part D of your “TDA Withdrawal Application” or “TDA Withdrawal Application for
Beneficiaries,” please complete the following:
I want
I want
I want
____
% (or $
% (or $
% (or $
) of my withdrawal to be directly rolled over to Program #1 in Part C.
) of my withdrawal to be directly rolled over to Program #2 in Part C.
) of my withdrawal to be directly rolled over to Program #3 in Part C.
Section 2: If you elected #4 in Part D of your “TDA Withdrawal Application” or “TDA Withdrawal Application for
Beneficiaries,” please complete the following:
% $
) of the funds that I designated for Direct Rollover to be directly rolled
% $
) of the funds that I designated for Direct Rollover to be directly rolled
I want
(or
over to Program #1 in Part C.
I want
(or
over to Program #2 in Part C.
PART C: Please list below the successor program(s) that you want to receive this Direct Rollover. If you elected #2 in Part D of your
“TDAWithdrawalApplication”or“TDAWithdrawalApplicationforBeneficiaries,”youmaylistuptothreeprograms;ifyou
elected #4, you may list up to two programs.
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PROGRAM #1
Name of Firm (check will be made payable to)
Type of Program (Check only one below)
IRA
Section 401(k) Plan
Name of Account
Account Number
Address
City
State
Zip Code
PROGRAM #2
Name of Firm (check will be made payable to)
Type of Program (Check only one below)
IRA
Section 401(k) Plan
Name of Account
Account Number
Address
City
State
Zip Code
PROGRAM #3 (You may complete this section only if you elected #2 in Part D of your “TDA Withdrawal Application” or
“TDA Withdrawal Application for Beneficiaries.”)
Name of Firm (check will be made payable to)
Type of Program (Check only one below)
Name of Account
IRA
Section 401(k) Plan
Account Number
Address
City
State
Zip Code
PART D: Please read the following and sign and date below.
I certify that I have read the information on pages 1 and 2 of this form.
I certify that, to the best of my knowledge, the successor program(s) named above is qualified to receive this Direct Rollover
under the applicable provisions of the Internal Revenue Code. I acknowledge that such certification is provided as a basis for TRS’
reasonable reliance on same.
SIGNATURE________________________________________________________DATE(M/D/Y)____________________
THIS FORM CANNOT BE PROCESSED UNLESS IT IS FILED WITH YOUR CORRECTLY COMPLETED
“TDA WITHDRAWAL APPLICATION” OR “TDA WITHDRAWAL APPLICATION FOR BENEFICIARIES.”
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