Get CA PR450001ROLLCPN 2012-2024

2. Mail the following to 1. Completed Rollover Request Form 2. Completed CERTIFICATION FORM Plan-to-Plan Transfers and Direct Rollovers PERS-MSD-354B. SIGNATURES REQUIRED Participant s Signature Date Separation Date As the employer I certify that the employee named above has terminated employment and is eligible to receive a distribution from the CalPERS Supplemental Income 457 Plan. Employer s Signature REV1012 PR450001ROLLCPN Page 1 of 2 Instructions for Rollover Request Process to Purchase CalPERS Service Credit Use this form if you intend to purchase service credit in the CalPERS pension plan at or after you permanently separate from employment for example when you leave employment or retire. Note Your request for service credit cost information form must have been received by CalPERS prior to retirement or separation of service to process this rollover request. 1. Complete Sections I through IV and sign the form in Section V. If this is your initial distribution from the permanently separated from employment. CALPERS ASSET ALLOCATION FUNDS CORE INVESTMENT FUNDS CalPERS Target Retirement Date Funds 1A 1B 1C 1D 1E 1F 1G 1H 1I 1J 1K Risk Based Funds Conservative Asset Allocation Fund Moderate Asset Allocation Fund Aggressive Asset Allocation Fund 8G 8H 8I Fixed Income Funds Short-Term Investment Fund PIMCO Short-Term Bond Fund CalPERS Total Return Bond Fund CalPERS Treasury Inflation Protected Securities Fund Equity Funds CalPERS S P 500 Equity Index Fund CalPERS Small/Mid Cap Equity Index Fund The Boston Company Small/Mid Value Fund CalPERS International Index Fund Pyramis International Select Fund TOTAL PERCENTAGE OF DISTRIBUTION MUST EQUAL 100 V. SIGNATURES REQUIRED Participant s Signature Date Separation Date As the employer I certify that the employee named above has terminated employment and is eligible to receive a distribution from the CalPERS Supplemental Income 457 Plan. Employer s Signature REV1012 PR450001ROLLCPN Page 1 of 2 Instructions for Rollover Request Process to Purchase CalPERS Service Credit Use this form if you intend to purchase service credit in the CalPERS pension plan at or after you permanently separate from employment for example when you leave employment or retire. Note Your request for service credit cost information form must have been received by CalPERS prior to retirement or separation of service to process this rollover request. FULL ACCOUNT ROLLOVER PARTIAL ACCOUNT ROLLOVER I hereby elect to rollover my account in full. IV. INVESTMENT DISTRIBUTION OPTIONS The rollover you are requesting will be distributed pro rata from your investment funds unless you specify a preference by indicating below the percentage of your withdrawal you want distributed from each Investment Option. Fund No. Fund Name Dist. CALPERS ASSET ALLOCATION FUNDS CORE INVESTMENT FUNDS CalPERS Target Retirement Date Funds 1A 1B 1C 1D 1E 1F 1G 1H 1I 1J 1K Risk Based Funds Conservative Asset Allocation Fund Moderate Asset Allocation Fund Aggressive Asset Allocation Fund 8G 8H 8I Fixed Income Funds Short-Term Investment Fund PIMCO Short-Term Bond Fund CalPERS Total Return Bond Fund CalPERS Treasury Inflation Protected Securities Fund Equity Funds CalPERS S P 500 Equity Index Fund CalPERS Small/Mid Cap Equity Index Fund The Boston Company Small/Mid Value Fund CalPERS International Index Fund Pyramis International Select Fund TOTAL PERCENTAGE OF DISTRIBUTION MUST EQUAL 100 V. SIGNATURES REQUIRED Participant s Signature Date Separation Date As the employer I certify that the employee named above has terminated employment and is eligible to receive a distribution from the CalPERS Supplemental Income 457 Plan. Employer s Signature REV1012 PR450001ROLLCPN Page 1 of 2 Instructions for Rollover Request Process to Purchase CalPERS Service Credit Use this form if you intend to purchase service credit in the CalPERS pension plan at or after you permanently separate from employment for example when you leave employment or retire. Date of Birth City State Zip Code Email Address EMPLOYER INFORMATION Agency Plan Number Employer Name 45 - ROLLOVER DISTRIBUTION OPTIONS You may elect to rollover all of your account or part of your account in order to purchase service credit with CalPERS. Please be aware that taking a full account rollover / distribution will permanently close the account. FULL ACCOUNT ROLLOVER PARTIAL ACCOUNT ROLLOVER I hereby elect to rollover my account in full. IV. INVESTMENT DISTRIBUTION OPTIONS The rollover you are requesting will be distributed pro rata from your investment funds unless you specify a preference by indicating below the percentage of your withdrawal you want distributed from each Investment Option. Fund No. Fund Name Dist. CALPERS ASSET ALLOCATION FUNDS CORE INVESTMENT FUNDS CalPERS Target Retirement Date Funds 1A 1B 1C 1D 1E 1F 1G 1H 1I 1J 1K Risk Based Funds Conservative Asset Allocation Fund Moderate Asset Allocation Fund Aggressive Asset Allocation Fund 8G 8H 8I Fixed Income Funds Short-Term Investment Fund PIMCO Short-Term Bond Fund CalPERS Total Return Bond Fund CalPERS Treasury Inflation Protected Securities Fund Equity Funds CalPERS S P 500 Equity Index Fund CalPERS Small/Mid Cap Equity Index Fund The Boston Company Small/Mid Value Fund CalPERS International Index Fund Pyramis International Select Fund TOTAL PERCENTAGE OF DISTRIBUTION MUST EQUAL 100 V. PLEASE NOTE You must be permanently separated from your employer before a rollover may be completed. PARTICIPANT INFORMATION Last Name First Name CalPERS ID Middle Initial Social Security Number Mailing Address number and street Telephone Number work II. Date of Birth City State Zip Code Email Address EMPLOYER INFORMATION Agency Plan Number Employer Name 45 - ROLLOVER DISTRIBUTION OPTIONS You may elect to rollover all of your account or part of your account in order to purchase service credit with CalPERS. Please be aware that taking a full account rollover / distribution will permanently close the account. FULL ACCOUNT ROLLOVER PARTIAL ACCOUNT ROLLOVER I hereby elect to rollover my account in full. IV. INVESTMENT DISTRIBUTION OPTIONS The rollover you are requesting will be distributed pro rata from your investment funds unless you specify a preference by indicating below the percentage of your withdrawal you want distributed from each Investment Option. Fund No. Fund Name Dist. Com P. O. Box 5166 Boston MA 02206-5166 1-800-260-0659 ROLLOVER REQUEST FORM for CalPERS SERVICE CREDIT PURCHASE I. PLEASE NOTE You must be permanently separated from your employer before a rollover may be completed. PARTICIPANT INFORMATION Last Name First Name CalPERS ID Middle Initial Social Security Number Mailing Address number and street Telephone Number work II. Date of Birth City State Zip Code Email Address EMPLOYER INFORMATION Agency Plan Number Employer Name 45 - ROLLOVER DISTRIBUTION OPTIONS You may elect to rollover all of your account or part of your account in order to purchase service credit with CalPERS. Please be aware that taking a full account rollover / distribution will permanently close the account. CalPERS Supplemental Income 457 Plan California Public Employees Retirement System CalPERS https //calpers.ingplans. com P. O. Box 5166 Boston MA 02206-5166 1-800-260-0659 ROLLOVER REQUEST FORM for CalPERS SERVICE CREDIT PURCHASE I. PLEASE NOTE You must be permanently separated from your employer before a rollover may be completed. PARTICIPANT INFORMATION Last Name First Name CalPERS ID Middle Initial Social Security Number Mailing Address number and street Telephone Number work II. .