TDA Annuitization Option Change Form (code RW87)

TDA ANNUITIZATION OPTION CHANGE FORM
INSTRUCTIONS
PLEASE READ CAREFULLY
• Please complete this form if you would like to change your previous Tax-Deferred Annuity (TDA) Program
annuitization option. Your option change would become effective upon receipt of a properly completed form.
• TDA participants may change their TDA annuitization option no later than 30 days after the date their TDA
annuitization took effect.
• Please note that, if you elect a continuing payment option (e.g., Options II, III, IV-a, IV-2, IV-3, or IV-4), you
may designate only one primary beneficiary. (You may not designate a trust as your beneficiary.) Under
the continuing payment options, your beneficiary’s age is a factor in computing the amount of your reduced
monthly annuity payments; therefore, you must also submit proof of your beneficiary’s date of birth.
The following items are considered acceptable proof of date of birth (only one of the following items is
necessary; a photocopy is acceptable): birth certificate; passport; or naturalization document. If none of the
preceding are available, then two of the following are required: photocopy of a driver’s license, governmentissued identification; certificate of military record; life insurance policy; baptismal certificate; or affidavit of
older relative. Any proof of date of birth in a foreign language must be accompanied by a translation.
• If you would like to change a beneficiary designation, you must also file the applicable change of beneficiary form.
• Several annuitization options are available to TDA annuitants. For complete descriptions of these options,
please consult the Retirement Payment Options: Tiers I/II and TDA Annuitization Options brochure.
• 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.
In Part A: All information must be provided.
In Part B: To change your TDA annuitization option, you must write your current TDA annuitization option in the space
provided and indicate the option to which you are switching by checking one of the options listed on pages 2 and 3 of this form.
In Part C: You must complete Part C only if you are switching to a continuing payment option (e.g., Options II, III, IV-a, IV-2,
IV-3, or IV-4). This beneficiary election is irrevocable. Therefore, if your beneficiary predeceases you, annuity payments
would cease upon your death. If you wish to change any other beneficiary information at this time, please submit the
appropriate change of beneficiary form in conjunction with this form.
In Part D: You must sign and date this form.
In Part E: You must have this form notarized.
RW87 (9/11) CONTINUED ON PAGE 2
PAGE 1
TDA ANNUITIZATION OPTION CHANGE FORM
Please read the instructions on page 1 before completing this form.
(NOTE: Please print in black or blue ink, and initial any changes that you make on this form.)
PART A: All information must be provided.
First Name
MI Last Name Permanent Home Address
Social Security Number (last 4 digits only)
XX X X X
Apt. No. Current TRS Membership Number
City State Zip Code
Effective Date of TDA Annuitization (M/D/Y)
Primary Phone Number (Check one:
(
)
Home
Alternate Phone Number (Check one:
(
)
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: Please write your current payment option in the space provided and check ONE of the payment options below if you want
to change your payment option. Write your initials on the line next to the box.
Current TDA annuitization option: ________________________________________________________
___
Maximum Payment Option—Greatest monthly annuity; no payments to beneficiary.
Note: No death benefit is payable under this option (other than the fractional annuity payment for the month in which you die).
___ Option I—Reduced monthly payments; lump-sum payment to beneficiary if account balance is not depleted.
___ Option IV-b—Reduced monthly payments; lump-sum payment to beneficiary based on the dollar amount you elect. I elect
that my beneficiaries receive a death benefit equaling $ ___________. (Must be in a multiple of $1,000, and amount may
not be greater than half the value of your TDA account balance as of your initial payability date.) I further elect that this
amount be payable from my funds in the following investment program (choose one):
Fixed ReturnDiversified EquityBond
RW87 (9/11) Inflation Protection
International Equity
CONTINUED ON PAGE 3
Socially Responsive Equity
PAGE 2
CONTINUED FROM PAGE 2
___
Option IV-d (“5-Year Certain”)—Reduced monthly payments; beneficiary receives monthly payments only if 60
reduced payments have not been made before your death; payments to beneficiary would stop after 60th overall
payment.
___
Option IV-e (“10-Year Certain”)—Reduced monthly payments (less than Option IV-d); beneficiary receives
monthly payments only if 120 reduced payments have not been made before your death; payments to beneficiary
would stop after the 120th overall payment.
Option II—Reduced monthly payments; no change to payments if your beneficiary predeceases you; lifetime
___
monthly payments equal to 100% of your reduced monthly annuity payments (if your beneficiary survives you).
___
Option III—Reduced monthly payments (greater than Option II); no change to payments if your beneficiary
predeceases you; lifetime monthly payments equal to 50% of your reduced monthly annuity payments (if your
beneficiary survives you).
___
Option IV-a—Reduced monthly payments (greater than Option II); no change to payments if your beneficiary
predeceases you; lifetime monthly payments equal to a percentage you choose (other than 100% or 50%) of your
reduced monthly annuity payments (if your beneficiary survives you).
I elect that the death benefit payment be ________% of my monthly annuity payment.
___
Option IV-2—Reduced monthly payments; if your beneficiary predeceases you, payment would “pop up” to the
maximum amount; lifetime monthly payments equal to 100% of your reduced monthly annuity payments (if your
beneficiary survives you).
Option IV-3—Reduced monthly payments (greater than Option IV-2); if your beneficiary predeceases you, payment
___
would “pop up” to the maximum amount; lifetime monthly payments equal to 50% of your reduced monthly annuity
payments (if your beneficiary survives you).
___
Option IV-4—Reduced monthly payments (greater than Option IV-2); if your beneficiary predeceases you, payment
would “pop up” to the maximum amount; lifetime monthly payments equal to a percentage you choose (other than
100% or 50%) of your reduced monthly annuity payments (if your beneficiary survives you).
I elect that the death benefit payment be ________% of my monthly annuity payment.
PART C: If you switch to a continuing payment option (e.g., Options II, III, IV-a, IV-2, IV-3, or IV-4), please designate only
one primary beneficiary. (This election is irrevocable.) Note: Please attach acceptable proof of your beneficiary’s date of birth.
Designation of Beneficiary Under an Option Providing Continuing Payments to your Beneficiary
(Options II, III, IV-a, IV-2, IV-3, or IV-4)
Beneficiary’s First Name
MI Last Name
Home Address
Apt. No.
City
Zip Code
State
Social Security Number
Relationship to You Date of Birth (M/D/Y)
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PAGE 3
CONTINUED FROM PAGE 3
PART D: Please read the following, and sign and date below.
I hereby elect to change my TDA annuitization option in accordance with Chapter 661 of the Laws of 2003 (Tiers I/II
members) or Chapter 446 of the Laws of 2004 (Tiers III/IV members). I acknowledge that this law entitles me to change my
TDA annuitization option under the following condition: I must file this form within 30 days of my effective annuitization date.
I understand that this TDA annuitization option change may entitle me to a TDA annuity under the option I elect, provided
that I meet the eligibility requirements.
MEMBER’S SIGNATURE__________________________________________ DATE (M/D/Y)____________________________
(must be the same as date of notarization)
PART E: TO BE COMPLETED BY A NOTARY (NOTE: Attestation made outside the U.S. must be executed before an
American consul.)
State of _____________________________ )
) s.s.:
County of ___________________________ )
On the ____________ day of _____________, __________, before me personally appeared the person known to me to
be___________________________________________________________, the individual who executed the foregoing
instrument and acknowledged to me that (s)he executed the same.
Signature:______________________________________________________
Official Title: ____________________________________________________
Expiration Date of Commission:_____________________________________
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