Get Pa Psrs-1264 2013

888. 773. 7748 www. psers. state. pa.us Authorization for Direct Rollover Retirement PSRS-1264 9/3/2013 INSTRUCTIONS You must complete and sign Part A of the Authorization for Direct Rollover form. The financial institution you choose must complete Part B of this form with an authorized signature. Commonwealth of Pennsylvania - Public School Employees Retirement System 5 N 5th Street Harrisburg PA 17101-1905 Toll-Free 1. The completed rollover form should be submitted with your Application for Retirement. Part A - Member Information Must be completed by member Member Name Apt or Suite Social Security No* Delivery Address Gender City Date of Birth State Zip Code Home/Cell Phone I understand. if my financial institution named in Part B will NOT accept a direct rollover because of the minimum threshold amount imposed by said financial institution or if the distribution is less than 100. 00 PSERS will make the payment to me minus 20 percent mandatory federal income tax. if I decide to change the financial institution after PSERS has processed my payment it is my responsibility to transfer the funds from the financial institution named in Part B to the new financial institution* I certify that I am the primary beneficiary and/or sole owner of the eligible retirement plan into which this amount is being directly rolled over. I hereby affirm that the foregoing information is true and correct to the best of my knowledge and belief said affirmation is being made subject to the penalties prescribed by 18 Pa* C. S*A. Section 4904 Unsworn Falsifications to Authorities. Member Signature required Date Part B - Financial Institution Information Must be completed by financial institution Depositor s Account Number optional Mailing Address State Zip Code 4 Internal Revenue Code IRC Sections 401 a 31 D 402 c 8 A and B. We further certify that the named account holder is the primary beneficiary and/or sole owner of this Eligible Retirement Plan* Please indicate in which type of eligible retirement plan the funds will be placed* IRA Other Please Specify Check this box only if this institution cannot accept tax-free funds. The completed rollover form should be submitted with your Application for Retirement. Part A - Member Information Must be completed by member Member Name Apt or Suite Social Security No* Delivery Address Gender City Date of Birth State Zip Code Home/Cell Phone I understand. if my financial institution named in Part B will NOT accept a direct rollover because of the minimum threshold amount imposed by said financial institution or if the distribution is less than 100. if my financial institution named in Part B will NOT accept a direct rollover because of the minimum threshold amount imposed by said financial institution or if the distribution is less than 100. 00 PSERS will make the payment to me minus 20 percent mandatory federal income tax. if I decide to change the financial institution after PSERS has processed my payment it is my responsibility to transfer the funds from the financial institution named in Part B to the new financial institution* I certify that I am the primary beneficiary and/or sole owner of the eligible retirement plan into which this amount is being directly rolled over. .