Maryland Form 193 – Fill Out and Use This PDF

MARYLAND STATE RETIREMENT AGENCY

120 EAST BALTIMORE STREET

BALTIMORE, MARYLAND 21202-6700

TRUSTEE-TO-TRUSTEE DISTRIBUTION FORM
	FOR ROLLOVERS		RETIREMENT USE ONLY Form 193 (REV. 4/13)
		SECTION I
To be completed by Payee and forwarded to Payee’s financial institution
Last Name	First	M.I.	Social Security				#
						-	-
MISCELLANEOUS:			Day Time Phone #
			( )			-	-
HOME ADDRESS:
			Ext
CITY:	STATE:	ZIP:

TYPE OF DISTRIBUTION: Check [4] Distribution Type:

Withdrawal of Accumulated Contributions (Form 5)

Withdrawal of Voluntary Funds (Form 742)

Application for Payment of Lump Sum Deferred Vested Benefit (Form 742.1)

Death Benefit (Surviving Spouse of Employee or Retiree) (Form 745)

Withdrawal of Deferred Retirement Option Program (DROP) Account (Forms 505; 757)

Based on the distribution option I selected on my Withdrawal ofAccumulated Contributions (Form 5), Withdrawal of Voluntary Funds (Form 742), Application for Payment of Lump Sum Deferred Vested Benefit (Form 742.1), Death Benefit Claim Form (Form 745) or Withdrawal of DROPAccount (Forms 505; 757), I direct the SRAto do the following:

Check [4] only one option to indicate payment selection.

Pay to me my designated flat dollar refund amount of $___________________.

OR

Pay to me all federal “NON-TAXABLE” funds to be determined at time of payment.

AND

The account balance will be made payable to your designated IRA or Eligible Employer Plan. (Note: distributions to a 457(b) governmental plan or a 403(b) tax sheltered annuity may not exceed the taxable amount.)

I understand the Agency may issue two checks to me: one payable to my order and the other payable to the order of the IRA or Eligible Employer Plan that is to receive my distribution. I understand that I am responsible for promptly delivering the check for my distribution directly to the IRA or Eligible Employer Plan for processing, and I agree to do so.

SRA will not process more than one trustee-to-trustee distribution. Thus, if you want to move funds between IRA’s and/or Eligible Employer Plans, contact the IRA or Eligible Employer Plan to which you are making the direct rollover to deter- mine whether transfers are allowable.

I understand and agree to the above distribution conditions.

PAYEE (Signature)

DATE

If you need assistance in completing this application, telephone a retirement benefits specialist at 410-625-5555 or toll-free at 1-800-492-5909.

SECOND PAGE ALSO MUST BE COMPLETED

SECTION II

(TO BE COMPLETED BY FINANCIAL INSTITUTION FOR PURPOSE OF ROLLOVER)

Verify Information in Section I.

Send completed form to: State Retirement Agency, 120 East Baltimore Street, Baltimore, Maryland 21202-6700

Payee’s Name: ______________________________________ Payee’s Social Security No. _________________- -

NAME AND ADDRESS OF FINANCIAL INSTITUTION/ACCOUNT

Name: ___________________________________________________________________________________

Address: _________________________________________________________________________________

City: _________________________________________ State: ________________ Zip: __________________

DEPOSITORACCOUNTTITLE:Inordertoproperlypreparethecheck,theRetirementAgencyneedsthenameofthefinancialinsti- tution/account into which the check will be made payable. Enter in the spaces below this information, up to 34 characters.The check payable to your designated financial institution/account will carry the notation “DIRECT ROLLOVER,” and will contain the name for the individual indicated in Section I. For IRA’s, the check will read payable to: [Information Below] as trustee of IND. RET. ACCT of [Payee in Section I]. For Eligible Employer Plans, the check will read payable to: [Information Below] FBO [Payee in Section I].

ENTER THE PAYEE’S ACCOUNT NUMBER (OPTIONAL):

The arrangement selected by the Payee is: (Check [4] one):

Check [4] Box to Affirm that Plan Separately

Traditional IRA

Eligible Employer Plan

Accounts for After-Tax Contributions & Earnings

Qualified plan under §401(a), including

Check indicates plan separately accounts

a 401(k) plan

for after-tax contributions and earnings

§403(a) qualified annuity

Check indicates plan separately accounts

Roth IRA

for after-tax contributions and earnings

§403(b) tax sheltered annuity

Plan may NOT accept after-tax contribu-

tions from a 401(a) qualified plan

§457(b) governmental plan

Plan may not accept after-tax contributions

I confirm that the payee, account number and title are correct. Further, I confirm that the plan designated by the payee is (or is intended to be) an IRA, or an Eligible Employer Plan which includes a plan qualified under section 401(a) of the Internal Revenue Code, including a 401(k) plan, profit sharing plan, defined benefit plan, stock bonus plan, and money purchase plan; a section 403(a) annuity plan; a section 403(b) tax sheltered annuity; or an eligible section 457(b) plan maintained by a governmental employer (governmental 457 plan), that the plan designated may accept such payment (including any after-tax contributions, if applicable) and that I am authorized to act on behalf of the designated plan and will accept the direct rollover for the payee and account for it as required by the Internal Revenue Code.

AREA CODE/TELEPHONE #:	-	-

PLEASE READ THIS CAREFULLY

All information on this form, including the individual’s social security number, is required. The information is confidential and will be used only to process payment data from the Maryland State RetirementAgency to the financial institution and its agent. Failure to provide the requested information may prevent or delay release or payment.

If you need assistance in completing this application, telephone a retirement benefits specialist at 410-625-5555 or toll-free at 1-800-492-5909.

FORM 193 (4/13) Pg. 2