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Get PA PSRS-1264 2015

888. 773. 7748 www. psers. state. pa.us Fax 717. 772. 3860 PSRS-1264 03/2015 Mail Center Authorization for Direct Rollover Retirement 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. All entries must be typed or legibly printed in black ink. Part A - Member Information Must be completed by member Member Name Apt No* or Suite Social Security No* Mailing 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 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 Signed Part B - Financial Institution Information Must be completed by financial institution Depositor s Account Number optional 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* The funds must be rolled over into one of these types of Eligible Retirement Plans Traditional IRA Governmental 457 b SEP-IRA Another defined benefit plan Check this box only if this institution cannot accept tax-free funds. The completed rollover form should be submitted with your Application for Retirement. All entries must be typed or legibly printed in black ink. Part A - Member Information Must be completed by member Member Name Apt No* or Suite Social Security No* Mailing Address Gender City Date of Birth State Zip Code Home/Cell Phone I understand. Part A - Member Information Must be completed by member Member Name Apt No* or Suite Social Security No* Mailing 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 PSERS will make the payment to me minus 20 percent mandatory federal income tax. 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 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. .

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