TDA Direct Rollover Election Form for Lump

TDA DIRECT ROLLOVER ELECTION FORM
FOR LUMP-SUM TDA DEATH BENEFIT
(FOR SPOUSE BENEFICIARIES ONLY)
INSTRUCTIONS
PLEASE READ CAREFULLY
• T
his form may be filed ONLY by a deceased TRS member’s surviving spouse who is the member’s
designated beneficiary under the Tax-Deferred Annuity (TDA) Program.
• T
his form must be filed in order to directly roll over all or part of a lump-sum death benefit from TRS’
TDA Program to one or more eligible Individual Retirement Arrangements (IRAs) or other successor
program(s).
• A
ccording to Internal Revenue Service (IRS) rules, a Direct Rollover is not allowed for any portion of a
death benefit that represents a Required Minimum Distribution (RMD) or that would not otherwise be
eligible for a rollover. Any RMD issued in conjunction with a Direct Rollover will be reported to the IRS
and indicated on a 1099-R form as a distribution.
• T
his form must be filed in conjunction with a correctly completed “Claimant’s Statement” (code DB17)
in order to be considered valid.
• If any of the below cases applies to you, do not file this form; instead, refer to your TRS Benefit
Package for further instructions and appropriate forms.
• You want 100% of your lump-sum TDA death benefit paid directly to you; or
• You want to roll over a Qualified Pension Plan (QPP) death benefit; or
• You are an eligible TDA beneficiary and you want to use the total amount of your TDA death
benefit to establish a TRS TDA Program account.
• 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 parts of this form.
In Part A: You must provide all information about the deceased TRS member.
In Part B: You must provide all information about yourself.
In Part C: 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 other successor program(s) that
you name. You may list a maximum of three programs under this election.
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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 other successor program(s) that you name. You may list a maximum
of two 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.
• 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 D: You must sign and date this form.
GENERAL PROVISIONS
• T
DA death benefits generally are federally taxable and may be subject to state and local taxes; please check
with your tax advisor.
• T
he Internal Revenue Service (IRS) requires that TRS withhold 20% of any portion of this benefit that you do not
instruct TRS to directly roll over into an IRA(s) or other successor program(s). This 20% would be sent to the IRS
as credit toward your federal taxes for the year of distribution.
• A
ny 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.
• T
he 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.)
• A
ny 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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TDA DIRECT ROLLOVER ELECTION FORM
FOR LUMP-SUM TDA DEATH BENEFIT
(FOR SPOUSE BENEFICIARIES ONLY)
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: Please provide the below information about the deceased TRS member.
First Name
MI Last Name Date of Birth (M/D/Y)
Social Security Number (last 4 digits only)
XX X X X
TRS Membership/Retirement Number
Date of Death­(M/D/Y)
PART B: Please provide the below information about yourself.
First Name
MI Last Name Permanent Home Address
City
State
Social Security Number
Apt. No.
Zip Code Date of Birth (M/D/Y)
Relationship to Deceased TRS Member
Primary Phone Number (Check one:
Home
Work
Mobile)
Alternate Phone Number (Check one:
Home
Work
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 file a “Beneficiary’s Change
of Address Form” (code DM14) with TRS.
If you are providing new information above, please indicate the effective date:
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PART C: 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 my benefit DIRECTLY ROLLED OVER to the eligible IRA(s) or other successor program(s) that I name
below; I understand that I may list up to three programs.
I want
% (or $
PROGRAM #1
Name of Firm
) of my benefit directly rolled over to:
Type of Account (Please check one)
IRA
Other successor program
Name of Fund/Account
Account Number
Address
City
I want
% (or $
PROGRAM #2
Name of Firm
Type of Account (Please check one)
IRA
Other successor program
Account Number
Address
City
% (or $
PROGRAM #3
Name of Firm
State
Zip Code
) of my benefit directly rolled over to:
Type of Account (Please check one)
IRA
Other successor program
Name of Fund/Account
Account Number
Address
City
DB34a (5/12) Zip Code
) of my benefit directly rolled over to:
Name of Fund/Account
I want
State
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State
Zip Code
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PART C (continued):
#2: I want my benefit distributed by the following combination of methods:
I want % (or $
) of my benefit PAID DIRECTLY to me in a check. I understand that TRS is required
to withhold 20% of the distribution paid directly 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 my benefit DIRECTLY ROLLED OVER to the eligible IRA(s) or other successor
program(s) that I name below; I understand that I may list up to two programs.
I want
% (or $
) of my benefit directly rolled over to:
PROGRAM #1
Name of Firm
Type of Account (Please check one)
IRA
Other successor program
Name of Fund/Account
Account Number
Address
City
I want
% (or $
State
Zip Code
) of my benefit directly rolled over to:
PROGRAM #2
Name of Firm
Type of Account (Please check one)
IRA
Other successor program
Name of Fund/Account
Account Number
Address
City
State
Zip Code
PART D: Please read the following statement and sign and date below.
I certify that I have read the instructions and information on this form.
I understand that this form must be filed in conjunction with a correctly completed “Claimant’s Statement” (code DB17) in order to be
considered valid.
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PART D (continued):
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 certify that I am the surviving spouse of the TRS member named in Part A, and that I am a designated beneficiary of this
member under the TDA Program.
SPOUSE BENEFICIARY’S SIGNATURE _______________________________________ DATE (M/D/Y) ________________
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