QPP Direct Rollover Election Form for Withdrawal_Distribution of

QPP DIRECT ROLLOVER ELECTION FORM
FOR WITHDRAWAL/DISTRIBUTION OF LUMP-SUM DISABILITY
BENEFIT/DEATH BENEFIT
INSTRUCTIONS
PLEASE READ CAREFULLY
• T
his form may be filed ONLY by a TRS member receiving a lump-sum disability benefit or by a TRS
member’s surviving spouse who is the designated spouse beneficiary.
• T
his form must be filed in order to roll over all or part of the taxable portion of a distribution (i.e., a
member’s lump-sum disability benefit or a spouse beneficiary’s lump-sum death benefit) received
from TRS’ Qualified Pension Plan (QPP) to one or more Individual Retirement Arrangements (IRAs)
or Section 401 Plans; any tax-free portion is not eligible for rollover and must be paid directly to
you. (Note for Tiers III, IV, and VI members: The entire balance in the Annuity Savings Accumulation
Fund (ASAF) is taxable.)
• D
o not file this form if you want 100% of your distribution paid directly to you; in this case, you only
need to file one of the forms listed in the next bullet. Do not file this form if you want to withdraw
funds from the Tax-Deferred Annuity (TDA) Program account; separate forms exist for that purpose.
• T
his form must be filed in conjunction with one of the following forms in order to be considered
valid: 1) “Claimant’s Statement” (code DB17); or 2) “Lump-Sum Disability Benefit Application”
(code DI25); or 3) Lump-Sum Disability Election Form” (code DI26).
• F
or 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 applicable parts of this form.
In Part A: For TRS members only: You must provide all information.
In Part B: For Spouse Beneficiary only: You must provide all information about the deceased TRS member.
In Part C: For Spouse Beneficiary only: You must provide all information about yourself.
In Part D: You must elect how your benefit will be distributed.
If you elect #1, TRS will directly roll over 100% of your benefit to the eligible IRA(s) or Section 401 Plan(s) that you name.
You may list a maximum of three eligible programs under this election.
If you elect #2, TRS will distribute your benefit by a combination of two methods: 1) Direct Payment by check and 2) Direct
Rollover to the eligible IRA(s) or Section 401 Plan(s) that you name. You may list a maximum of two eligible programs
under this election. Please note the following:
• If you write in the percentage(s) you wish to designate for each distribution method (i.e., Direct Payment and Direct
Rollover), the total must equal 100%; otherwise, your form(s) would be canceled.
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• If you know the exact amount of your distribution, you may write in the dollar amount you wish to designate for
each distribution method (i.e., Direct Payment and Direct Rollover).
• If you do not know the exact amount of your distribution, you may designate a dollar amount for one distribution
method and write “the balance” in the “$” box for the remaining distribution method.
In Part E: You must sign and date this form as either a TRS member or a Spouse Beneficiary, as applicable.
GENERAL PROVISIONS
• Internal Revenue Service (IRS) rules require that TRS withhold 20% of any taxable portion of this benefit that you
do not instruct TRS to directly roll over into an IRA(s) or Section 401 Plan(s). This 20% would be sent to the IRS
as credit toward your federal taxes for the year of distribution. (Within 60 days of the distribution date, you may
roll over any taxable amount you receive, or roll over the entire amount of the distribution by replacing the 20%
withheld by TRS with money from other sources.)
• Any amount that is distributed through a Direct Rollover is not taxable until it is received as income. The 20%
withholding will not apply to these amounts.
• The minimum amount that TRS will directly roll over to a successor program is $200. (This minimum amount may
be greater depending on the successor program’s minimum requirements.)
• Any payment of less than $200 will be sent directly to you and will not be subject to the 20% withholding; this
includes any payment based on a percentage election made on this form that is calculated to be less than $200.
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QPP DIRECT ROLLOVER ELECTION FORM
FOR WITHDRAWAL/DISTRIBUTION OF LUMP-SUM DISABILITY
BENEFIT/DEATH BENEFIT
Please read the instructions on pages 1 and 2 before completing this form.
(NOTE: Please print in black or blue ink, and initial any changes that you make on this form.)
PART A: To be completed by TRS member; please provide the information below.
First Name
MI Last Name Permanent Home Address
Social Security Number (last 4 digits only)
XX X X X
Apt. No. TRS Membership Number
City State Zip Code
Primary Phone Number (Check one:
(
)
Alternate Phone Number (Check one:
(
)
Home
Home
Work
Work
Mobile)
Mobile)
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, TRS suggests that you consult the U.S. Postal Service about having your mail forwarded
on a temporary basis. To register any changes to your permanent address (and/or phone number), please access our website or file a
“Member’s Change of Address Form” (code DM13) with TRS.
If you are providing new information above, please indicate the effective date:
PART B: To be completed by Spouse Beneficiary; please provide the information below about the deceased member of TRS.
First Name
Date of Birth (M/D/Y)
MI Last Name
Date of Death (M/D/Y)
Social Security Number (last 4 digits only)
XX X X X
TRS Membership/Retirement Number
PART C: To be completed by Spouse Beneficiary; please provide the information below about yourself.
First Name
MI Last Name Permanent Home Address
Apt. No. Date of Birth (M/D/Y)
City State Zip Code
DB32 (2/13)
Social Security Number
Primary Phone Number (Check one:
(
)
Alternate Phone Number (Check one:
(
CONTINUED ON PAGE 4
)
Home
Home
Work
Work
Mobile)
Mobile)
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PART C (continued):
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, TRS suggests that you consult the U.S. Postal Service about having your mail forwarded
on a temporary basis. To register any changes to your permanent address (and/or phone number), please file a “Beneficiary’s Change
of Address Form” (code DM14) with TRS.
If you are providing new information above, please indicate the effective date:
PART D: Please elect ONE of the following two choices (#1 or #2), and write your initials in the space provided next to your choice.
#1: I want 100% of the taxable portion of this benefit DIRECTLY ROLLED OVER to the eligible IRA(s) or Section 401 Plan(s)
that I name below; I understand that I may list up to three programs. (I also understand that any tax-free portion of this
distribution is not eligible for rollover and will be paid directly to me.)
I want % (or $ ) of my benefit to be directly rolled over to:
PROGRAM #1
Name of Firm
Type of Account (Please check one)
Name of Fund/Account IRA
Section 401 Plan
Account Number
Address
City
State
Zip Code
I want % (or $ ) of my benefit to be directly rolled over to:
PROGRAM #2
Name of Firm Type of Account (Please check one)
IRA
Name of Fund/Account Account Number
Address
City
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Section 401 Plan
State
Zip Code
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PART D (continued):
I want % (or $ ) of my benefit to be directly rolled over to:
PROGRAM #3
Name of Firm Type of Account (Please check one)
IRA
Name of Fund/Account Account Number
Address
City
Section 401 Plan
State
Zip Code
#2: I want this benefit to be distributed by the following combination of methods:
(I understand that any tax-free portion of this distribution is not eligible for rollover and will be paid directly to me.)
I want
% (or $
) of this benefit PAID DIRECTLY to me in a check. I understand that TRS
is required to withhold 20% of the taxable amount distributed to me, that this withheld amount will be forwarded to
the IRS, and that I may claim the amount withheld as federal tax paid on my tax return for the year of distribution.
AND
I want
% (or $
) of the taxable portion of this benefit to be DIRECTLY ROLLED OVER
to the eligible IRA(s) or Section 401 Plans that I name below; I understand that I may list up to two programs.
I want % (or $ ) of my benefit to be directly rolled over to:
PROGRAM #1
Name of Firm Type of Account (Please check one)
IRA
Name of Fund/Account Account Number
Address
City
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Section 401 Plan
State
Zip Code
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PART D (continued):
I want % (or $ ) of my benefit to be directly rolled over to:
PROGRAM #2
Name of Firm
Type of Account (Please check one)
Name of Fund/Account
IRA
Section 401 Plan
Account Number
Address
City
State
Zip Code
PART E: Please read the following and sign and date as applicable.
I certify that I have read the instructions and information on this form.
I certify that 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.
I am aware that, by law, I must be given notice of a distribution not less than 30 days, or more than 90 days,
prior to receiving it. I hereby waive this right.
I certify that I am a TRS member receiving a lump-sum disability benefit.
MEMBER’S SIGNATURE__________________________________________________DATE (M/D/Y) ________________
OR
I certify that I am a TRS member’s designated spouse beneficiary.
SPOUSE BENEFICIARY’S SIGNATURE_____________________________________DATE (M/D/Y) _________________
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