Form Rsa 10 D D – Fill Out and Use This PDF

RSA 10 D-D	REQUEST FOR DROP DISTRIBUTION AND ROLLOVER ELECTION
02/10		Check One:
1M	Retirement Systems of Alabama
	P. O. Box 302150  Montgomery, AL 36130-2150	 ERS
	334-517-7000 or 877-517-0020	 TRS
	www.rsa-al.gov

Please type or print using black ink.

PART I MEMBER INFORMATION

Name:						Social Security No.:		-	-
		First	Middle	Last
Address:						Home Phone Number: (		)
			Street Address or P. O. Box
City			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

, COUNTY OF

On this

day of

, 20

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.

PART III TRUSTEE INFORMATION (To be completed by Trustee receiving the rollover)

Member Name:

Social Security No.:

-

-

First

Middle

Last

Trustee Name:

Account Number:

Contact Person:

Phone No.: (

)

Address:

Street Address or P. O. Box

City

State

Zip

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

 403(a) Annuity Contracts

 403(b) Tax Sheltered Annuity

408(a) Individual Retirement Account  408(b) Individual Retirement Annuity  Governmental Deferred Compensation

 Roth IRA

Compensation Plans (IRC 457)

An Education IRA is not an eligible plan.

Signature of Trustee Official

Date:

Please submit the completed form to the RSA at the address on the front of this form.