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Member Signature Date TRUSTEE INFORMATION to be completed by trustee Trustee Name Please Print Trustee Address Account Number Please indicate the transferring plan type Individual Retirement Account - 408 a -orIndividual Retirement Annuity - 408 b 403 a Annuity Plan 403 b Tax-Sheltered Annuity Qualified Defined Benefit or Contribution Plan 401 a or 401 k Governmental Deferred Compensation Plan - 457 Note Transfers from Inherited IRAs Roth IRAs and Inherited Roth IRAs are not permitted. Name Title of Authorized Plan Administrator Please Print Signature of Authorized Plan Administrator Please return the completed form to the address below and enclose a check payable to NYSLRS. NYSLRS Attn Member Accounts Mail Drop 5-1 Albany NY 12244 The New York State and Local Retirement System NYSLRS is a qualified plan under Section 401 a of the Internal Revenue Code. Office of the New York State Comptroller New York State and Local Retirement System Employees Retirement System Police and Fire Retirement System 110 State Street Albany New York 12244-0001 Application for Direct Trustee-to-Trustee Transfer for Purchase of Optional Service Credit RS2416 Phone 1-866-805-0990 or 518-474-7736 Fax 518-474-2142 or 518-474-9898 Web www. osc*state. ny. us/retire Rev* 7/10 Complete the section below and mail this form with a copy of your arrears cost letter to the administrator of the retirement account or plan from which you are transferring funds. MEMBER INFORMATION to be completed by member Name Please Print Social Security Number Home Address Retirement Registration Number City State Zip Date of Birth Work Telephone Number Home Telephone Number I authorize the transfer of to be received no later than. The transfer does not include after-tax contributions nor is the amount greater than the amount quoted on the cost letter for the purchase of service. I assume responsibility for any tax consequences that result if the certifications on this form are not correct. Office of the New York State Comptroller New York State and Local Retirement System Employees Retirement System Police and Fire Retirement System 110 State Street Albany New York 12244-0001 Application for Direct Trustee-to-Trustee Transfer for Purchase of Optional Service Credit RS2416 Phone 1-866-805-0990 or 518-474-7736 Fax 518-474-2142 or 518-474-9898 Web www. osc*state. ny. us/retire Rev* 7/10 Complete the section below and mail this form with a copy of your arrears cost letter to the administrator of the retirement account or plan from which you are transferring funds. osc*state. ny. us/retire Rev* 7/10 Complete the section below and mail this form with a copy of your arrears cost letter to the administrator of the retirement account or plan from which you are transferring funds. MEMBER INFORMATION to be completed by member Name Please Print Social Security Number Home Address Retirement Registration Number City State Zip Date of Birth Work Telephone Number Home Telephone Number I authorize the transfer of to be received no later than.