Urs Form Difa 1 – Fill Out and Use This PDF

INSTRUCTIONS: 1. Use this form to make any single sum or rollover contribution to the URS Traditional or the URS Roth IRA.

2.Review both sides of this form before completing.

3.Please type or print clearly in black ink.

4.Personal contributions require a minimum deposit of $100.

5.If you fax this form, do not mail the original.

SECTION A - GENERAL INFORMATION

SECTION B - REQUIREMENTS FOR DEPOSIT

You must have established a URS IRA.

Transfers and rollovers must be from another eligible plan. (See back for details.)

Payments made to you, which you then roll into the URS Traditional or Roth IRA, must be completed within 60 days. Checks should be made payable to Utah Retirement Systems. Your name and Social Security number or URS account number must be noted on the check.

SECTION D - DEPOSIT INSTRUCTIONS

Source of Funds

Personal Contribution Can be a personal check, cashier's check, money order, or cash; must be an amount of $100 or more.

Contribution in the amount of $ _________________________________ for the current tax year.	20 _______
Contribution in the amount of $ _________________________________ for the prior tax year.	20 _______

(Additional information and instructions about contribution deadlines are available on the back of this form.)

Transfer/Rollover from another traditional or Roth IRA; from another eligible plan (401(k), 401(a), 403(b), 457 plan).

Transfer/Direct Rollover Indicate type of plan funds are coming from: ____________________________________

Approximate amount of transfer/rollover $ _________________________

60-Day Rollover (if you received a check from your previous plan within the last 60 days). Amount of rollover $ _________________________

SECTION E - CERTIFICATION AND SIGNATURE

I accept full responsibility for complying with all IRS requirements with respect to my URS IRA, including, but not limited to, contribution limits, conversions, distributions, recharacterizations, required minimum distributions, and tax-filing and record-keeping requirements. I understand that I am responsible for any tax consequences or penalties which may result from elections I make or any contributions, conversions, or recharacterizations I initiate.

If I have indicated a 60-day rollover above, I certify that: such distribution was received within 60 days of making the rollover to this IRA; no portion of the amount rolled over is a required minimum distribution under required minimum distribution rules; and if the distribution is from another IRA, I have not made another rollover within the one-year period immediately preceding this rollover.

DIFA-1 rev. 05/06/2009

IMPORTANT INFORMATION CONCERNING IRA CONTRIBUTIONS

IRA Contribution Deadlines

Contributions to an IRA can be made at any time, from January 1 of one year, until the tax filing deadline (generally April 15) of the following year. For example, a contribution for the 2009 tax year may be made any time from January 1, 2009, until April 15, 2010.

All contributions received via payroll deduction will be reported for the calendar year deposited. Any contributions for a prior tax year MUST be made by cashier's check or money order.

IMPORTANT NOTE:

If you choose to make a contribution to the URS Traditional or URS Roth IRA for a prior year, a completed URS IRA Deposit Authorization Form AND a personal check, cashier's check, money order, or cash must be received at the URS offices no later than 5:00 pm Mountain Time on the tax filing deadline (generally April 15).

INFORMATION CONCERNING TRANSFER/ROLLOVER TO THE URS TRADITIONAL OR ROTH IRA

Instructions for Deposit into the URS Traditional and Roth IRA

If you choose to deposit, transfer, or rollover funds from another eligible plan into the URS Traditional or URS Roth IRA, have the check made payable as follows:

Utah Retirement Systems

PO Box 1590

Salt Lake City, Utah 84110-1590

Please include your name, Social Security number or URS account number on the check, along with this form, to ensure prompt deposit of funds.

Transfer/Rollover Limits

There are no limits on amounts that may be transferred or rolled over to the URS Traditional or Roth IRA. Funds transferred or rolled over do not restrict you from making a regular contribution up to the limits indicated above.

Eligible Plans for Transfer/Rollover to the URS Traditional IRA

Retirement plans eligible for rollover to the URS Traditional IRA include: 401(k), 403(b), 401(a), and 457 plans. IRA plans eligible for transfer to

the URS Traditional IRA include: traditional IRA, SEP-IRA, and SARSEP plans. SIMPLE IRA plans may be rolled into the URS Traditional IRA provided you have been a participant in the SIMPLE IRA plan for at least two years prior to the rollover.

Eligible Plan for Transfer to the URS Roth IRA

The URS Roth IRA will accept funds transferred from another Roth IRA, Roth 401(k), or Roth 403(b). The URS Traditional IRA may be converted to the URS Roth IRA. If you wish to convert an existing URS Traditional IRA to the URS Roth IRA, you must complete the URS Traditional to Roth IRA Conversion Form. You can also roll over a pre-tax 401(k), 403(b), or 457 directly into the Roth IRA. There is no limit to the amount of pre-tax funds you can roll over to the Roth IRA, but because the rollover is taxable, it could affect your tax situation substantially.

Rollover and Transfer Defined

There are two types of ROLLOVERS* :

A DIRECT ROLLOVER allows you to move a distribution from one eligible plan to a different type of eligible plan. A direct rollover occurs when a distribution from an eligible plan is paid directly to URS. A direct rollover requires no federal tax withholding or any early withdrawal penalty tax.

A 60-DAY (INDIRECT) ROLLOVER allows you to move eligible plan assets to another plan within 60 days of receiving the distribution. Distributions may be subject to mandatory tax withholding. You may replace any amount that was withheld. Any portion of the distribution that is not rolled over, including any taxes that are withheld and not replaced, is treated as a taxable withdrawal, and may be subject to an additional 10% early withdrawal penalty tax. Only one 60-day rollover from an IRA can occur each twelve-month period.

A TRANSFER is between similar plans (i.e. traditional IRA to traditional IRA, 457 plan to 457 plan). There is no limit to the number of transfers permitted.

*It is important to be aware that the rollover funds may be subject to the rules and regulations governing the new plan. Therefore, when taking a distribution from the new plan, you may be subject to the restrictions and tax consequences which are different from those of the original plan.

Investment of Deposit

Your transfer/rollover will be deposited based on the investment allocation for future contributions you currently have on file with URS. If no such allocation election has been made, funds will be invested in the stable value option (currently the Income Fund). You may elect to change your current allocation or transfer balances among investment options by completing an IRA Investment Contract and submitting it to URS, or by using my URS at www.urs.org.

DIFA-1 rev. 05/06/2009