form 193-12_form193

MARYLAND STATE RETIREMENT AGENCY
120 EAST BALTIMORE STREET
BALTIMORE, MARYLAND 21202-6700
TRUSTEE-TO-TRUSTEE DISTRIBUTION FORM
FOR ROLLOVERS
RETIREMENT USE ONLY
Form 193 (REV. 7/16)
Purpose of this form: This form is used by an individual applying to receive a lump sum payment from the
Maryland State Retirement Agency and who wants to rollover all or a portion of the payment to another qualified retirement plan.
Instructions
For assistance in completing this form, please view the training video on the
Retirement Agency’s website at sra.maryland.gov.
•
•
•
Section I of this form is to be completed by the
individual (the Payee) who is applying to receive
the lump sum payment from the Retirement
Agency.
Section II of this form is to be completed by a
representative of the financial institution who will
be accepting the rollover.
The completed form must be returned to the
Maryland State Retirement Agency, 120 E.
Baltimore Street, Baltimore, Maryland 212026700.
FORM 193 (7/16) Page 1 of 3
•
•
•
Please print in ink, using one space per letter or
number and skipping a space between words.
Keep a copy of the completed form for your
records.
If, after viewing the training video, you need additional assistance, please contact a retirement
benefits specialist at 410-625-5555 or toll-free 1800-492-5909
SECTION I — To be completed by the Payee
SOCIAL SECURITY NUMBER
-
DAYTIME PHONE NUMBER
-
-
-
Ext. _____________
NAME
First
HOME ADDRESS
Initial
Last
Number and Street
City
State
ZIP Code
TYPE OF DISTRIBUTION: Check [4] Distribution Type:
Withdrawal of Accumulated Contributions (Form 5)
Withdrawal of Voluntary Funds (Form 742)
Application for Payment of Lump Sum Deferred Vested Benefit (Form 742.1)
Death Benefit (Surviving Spouse of Employee or Retiree) (Form 745)
Withdrawal of Deferred Retirement Option Program (DROP) Account (Forms 505; 757)
Based on the distribution option I selected on my Withdrawal of Accumulated Contributions (Form 5), Withdrawal of
Voluntary Funds (Form 742), Application for Payment of Lump Sum Deferred Vested Benefit (Form 742.1), Death Benefit
Claim Form (Form 745) or Withdrawal of DROP Account (Forms 505; 757), I direct the SRA to do the following:
Check [4] only one option to indicate payment selection.
Pay to me my designated flat dollar refund amount of $___________________.
OR
Pay to me all federal “NON-TAXABLE” funds to be determined at time of payment.
AND
The account balance will be made payable to your designated IRA or Eligible Employer Plan. (Note: distributions to a
457(b) governmental plan or a 403(a) annuity may not exceed the taxable amount.)
I understand the Agency may issue two checks to me: one payable to my order for an amount I elect to receive and the
other payable to the order of both me and the IRA or Eligible Employer Plan that is to receive my rollover distribution. I
understand that I am responsible for delivering the check for my rollover distribution directly to the IRA or Eligible
Employer Plan for processing within 60 days after I receive the check, and I agree to do so.
SRA will not process more than one trustee-to-trustee distribution. Thus, if you want to move funds between IRA’s and/or
Eligible Employer Plans, contact the IRA or Eligible Employer Plan to which you are making the direct rollover to determine whether transfers are allowable.
I understand and agree to the above distribution conditions.
PAYEE (Signature):
DATE:
NEXT PAGE ALSO MUST BE COMPLETED
For help in completing this form, please view the training video on the Retirement Agency’s website at sra.maryland.gov.
If you need additional assistance, telephone a retirement benefits specialist at 410-625-5555 or toll-free at 1-800-492-5909.
FORM 193 (7/16) Page 2 of 3
SECTION II — To be completed by a representative of
the financial institution that will accept the rollover
PAYEE’S NAME
First
Initial
Last
PAYEE’S SOCIAL SECURITY NUMBER
-
-
DEPOSITOR ACCOUNT TITLE: In order to properly prepare the check, the Retirement Agency needs the name of the
financial institution/account into which the check will be made payable. Enter in the spaces below this information, up to
34 characters. The check payable to your designated financial institution/account will carry the notation “DIRECT
ROLLOVER,” and will contain the name for the individual indicated in Section I. For IRA’s, the check will read payable to:
[Information Below] as trustee of IND. RET. ACCT of [Payee in Section I]. For Eligible Employer Plans, the check will read
payable to: [Information Below] FBO [Payee in Section I].
The arrangement selected by the Payee is: (Check [4] one):
Traditional IRA
Check [4] Box to Affirm that Plan Separately
Accounts for After-Tax Contributions & Earnings
Eligible Employer Plan
Qualified plan under §401(a), including
a 401(k) plan
Check indicates plan separately accounts
for after-tax contributions and earnings
§403(a) qualified annuity
Plan may NOT accept after-tax contributions from a 401(a) qualified plan
§403(b) tax sheltered annuity
Check indicates plan separately accounts
for after-tax contributions and earnings
§457(b) governmental plan
Plan may not accept after-tax contributions
Roth IRA
I confirm that the payee, account number and title are correct. Further, I confirm that the plan designated by the payee is
(or is intended to be) an IRA, or an Eligible Employer Plan which includes a plan qualified under section 401(a) of the
Internal Revenue Code, including a 401(k) plan, profit sharing plan, defined benefit plan, stock bonus plan, and money purchase plan; a section 403(a) annuity plan; a section 403(b) tax sheltered annuity; or an eligible section 457(b) plan maintained by a governmental employer (governmental 457 plan), that the plan designated may accept such payment (including any after-tax contributions, if applicable) and that I am authorized to act on behalf of the designated plan and will accept
the direct rollover for the payee and account for it as required by the Internal Revenue Code.
PRINT OR TYPE REPRESENTATIVE’S NAME
REPRESENTATIVE’S AREA CODE/TELEPHONE:
SIGNATURE OF REPRESENTATIVE
-
DATE
-
PLEASE READ THIS CAREFULLY: All information on this form, including the individual’s Social Security number, is required. The information is confidential and will be used only to process payment data from the Maryland
State Retirement Agency to the financial institution and its agent. Failure to provide the requested information
may prevent or delay release or payment.
For help in completing this form, please view the training video on the Retirement Agency’s website at sra.maryland.gov. If you
need additional assistance, telephone a retirement benefits specialist at 410-625-5555 or toll-free at 1-800-492-5909.
FORM 193 (7/16) Page 3 of 3