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17101-1716 800 633 - 5461 www.sers.state.pa.us AUTHORIZATION FOR DIRECT ROLLOVER Instructions: 1. Member completes PART 1 and forwards to their Financial Institution. 2. Financial Institution completes PART 2 and returns the form to SERS. PART 1 - MEMBER AGREEMENT SSN: Name: Telephone Number Date of Retirement: (if Applicable) First Middle Reason for Rollover (check one) Last Refund Address Retirement City State Installment Zip Code The IRS has acknowledged the status of SERS as.

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