Form Ri 38-122 - Alternative Annuity And Rollover Election - Thrift Savings Plan

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Alternative Annuity and Rollover Election
Name (last, first, middle)
Social Security Number
Please read all of the information in the Alternative Annuity Election Information For
Employees, Form RI 38-123, before completing this form.
I. Alternative Annuity
I do not want to make an election at this time. I want OPM to send me the complete alternative annuity election package.
I understand my application for retirement will not be processed until after I receive and return the election form.
Provide your signature below and return this form to your Personnel Office. Do not check any of the following blocks.
Your signature
Date
I elect to receive a reduced alternative annuity and a lump-sum payment of my retirement contributions. If I am married,
the consent of my spouse is shown below in Part II. I do not have a former spouse who is entitled by court order to a
portion of my annuity or a survivor annuity.
II. Spousal Consent
Your spouse must sign in the presence of a notary or other person authorized to administer oaths.
I freely consent to this alternative annuity election.
Signature of current spouse
Notarization—To be completed by notary public or other official authorized to administer oaths.
I certify that the person whose signature appears immediately above presented
identification (or was known to me), gave consent to the specific election as executed by
(Seal)
the employee, signed or marked the form, and acknowledged that the consent was freely
given in my presence.
Signature
Expiration date of commission
Date
III. Rollover Election
Complete one of the following options
Pay my lump sum directly to me. I understand that the Office of Personnel Management is required to withhold 20% of
any taxable portion for Federal income tax and that to defer income tax I have the option to roll over part or all of any
taxable portion within 60 days after receipt into a traditional IRA or an eligible employer plan.
Pay $_________ (enter "all" or a dollar amount at or above $500) of my lump sum to ____________________________
with no Federal income tax withheld from any taxable portion.
Is this a Roth IRA?
Yes
No
Do you elect to have Federal income tax withheld?
Yes
No
Pay any remainder to me, less 20% Federal income tax withholding from any taxable portion paid to me.
Send the payment to my account.
Send the payment to me, made payable to my account. I will
deliver it to the account within 60 days.
Provide your certification: By my signature below, I certify that I have read and understood the information in the
accompanying Alternative Annuity Election Information For Employees notice. I certify that I do not have a former spouse
entitled by court order to receive a portion of my annuity or a survivor annuity.
Warning: Any intentionally false or willfully misleading statement or response you provide in this election is a violation of
the law punishable by a fine of not more than $10,000 or imprisonment of no more than 5 years, or both. (18 U.S.C. 1001)
Signature
Date
RI 38-122
(Continued on reverse)
This form may be locally reproduced
Revised August 2010
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