Get Rsa Alabama Retirement Form

REQUEST FOR DROP DISTRIBUTION AND ROLLOVER ELECTION RSA 10 D-D 02/10 1M Check One ERS TRS Retirement Systems of Alabama P. O. Box 302150 Montgomery AL 36130-2150 334-517-7000 or 877-517-0020 www. rsa-al*gov Please type or print using black ink. PART I MEMBER INFORMATION Name First Middle Address Last Home Phone Number Street Address or P. O. Box City Social Security No* State Country - Zip PART II DISTRIBUTION OPTION Please read the enclosed special tax notice before completing the remainder of this form* Select only one of the following Lump Sum Payment I elect to receive at the above address full distribution of my DROP account less the 20 Federal Income Tax withholding required* Sign and have your signature notarized* Submit the form to the RSA at the address above. Do not complete Part III. I elect to have the entire DROP account balance rolled over into an eligible retirement account listed under Part III. I elect to have of the taxable funds rolled over to an eligible retirement account listed under Part III. The remaining taxable funds will be paid to me less the required 20 Federal Income Tax Withholding. Any non-taxable funds will be paid directly to me with no federal withholding. List the eligible retirement plan you have elected to have your funds rolled into RSA-1 or Other Note If you have all or a portion of your DROP account rolled over into an eligible retirement account you must sign and have your signature notarized before sending this form to your Trustee to complete Part III. I certify that I have received the printed explanation entitled Special Tax Notice Regarding Your Rollover Options prior to signing this certification* Signature Date STATE OF On this COUNTY OF day of before me the undersigned authority a Notary Public in and for said County and State personally appeared before me the above named individual known to me to be the person who subscribed to the foregoing instrument. Signature of Notary Public Seal My Commission Expires PART III TRUSTEE INFORMATION is on the reverse side of this form* Member Name Trustee Name Account Number Contact Person Phone No* Plan accepts non-taxable funds. Plan does not accept non-taxable funds. Type of account into which money will be rolled over 401 Qualified Retirement Plan 408 a Individual Retirement Account Roth IRA 403 a Annuity Contracts 403 b Tax Sheltered Annuity Compensation Plans IRC 457 An Education IRA is not an eligible plan* Signature of Trustee Official Please submit the completed form to the RSA at the address on the front of this form*. O. Box 302150 Montgomery AL 36130-2150 334-517-7000 or 877-517-0020 www. rsa-al*gov Please type or print using black ink. PART I MEMBER INFORMATION Name First Middle Address Last Home Phone Number Street Address or P. O. Box City Social Security No* State Country - Zip PART II DISTRIBUTION OPTION Please read the enclosed special tax notice before completing the remainder of this form* Select only one of the following Lump Sum Payment I elect to receive at the above address full distribution of my DROP account less the 20 Federal Income Tax withholding required* Sign and have your signature notarized* Submit the form to the RSA at the address above.