Form Ri 38-122 - Alternative Annuity And Rollover Election - Thrift Savings Plan Page 2
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2IV. Certification by Financial Institution or Eligible Employer Plan
Name of institution or eligible employer plan
Address of institution or plan
IRA account number or plan identification
Certification: My signature below confirms the account number for the individual named on page 1. As a representative of the financial
institution or plan named above, I certify that this institution or plan agrees to accept the funds described above as a direct
trustee-to-trustee transfer from the Office of Personnel Management, to deposit them in an eligible IRA or eligible employer plan as
defined in the Internal Revenue Code, and to account for these monies in compliance with the Internal Revenue Code. I understand that
my signature below authorizes the transfer of taxable and/or non-taxable funds as indicated on page 1.
Typed or printed name of certifying representative
Telephone number (including area code)
Signature of certifying representative
Date of certification (mm/dd/yyyy)
Name of institution or eligible employer plan
Address of institution or plan
IRA account number or plan identification
Certification: My signature below confirms the account number for the individual named on page 1. As a representative of the financial
institution or plan named above, I certify that this institution or plan agrees to accept the funds described above as a direct
trustee-to-trustee transfer from the Office of Personnel Management, to deposit them in an eligible IRA or eligible employer plan as
defined in the Internal Revenue Code, and to account for these monies in compliance with the Internal Revenue Code. I understand that
my signature below authorizes the transfer of taxable and/or non-taxable funds as indicated on page 1.
Typed or printed name of certifying representative
Telephone number (including area code)
Signature of certifying representative
Date of certification (mm/dd/yyyy)
Instructions for Rollover to the Federal Retirement Thrift Savings Plan
The Thrift Savings Plan (TSP) will not accept non-taxable (post-tax) monies. You must have an open TSP account. Before
the Office of Personnel Management (OPM) can complete a rollover to your Thrift Savings account, you must sign and submit
Form TSP-60, Request for a Transfer into the TSP, to OPM. Submit both the TSP-60 and this form at the same time. OPM
will complete its portion of the TSP-60 and fax it to the Thrift Savings office for processing. The form must be approved by
the Thrift Savings Board and the Board must notify OPM to transfer the funds. This process can take two to three weeks. Form
TSP-60 is available on the internet at
Privacy Act Statement
Solicitation of this information is authorized by Chapters 83 and 84, title 5, U.S. Code. The information you furnish will be used to obtain
additional information, if necessary, and to determine and allow present or future benefits. The information may be shared and is subject to
verification via paper, electronic media, or through the use of computer matching programs, with national, state, local, or other charitable or
social security administrative agencies in order to determine benefits under their programs, to obtain information necessary for
determination of benefits under this program, or to report income for tax purposes. It may also be shared or verified, as noted above, with
law enforcement agencies when they are investigating a violation or potential violation of civil or criminal law. Executive Order 9397
(November 22, 1943) authorizes the use of the Social Security Number. Furnishing this information is voluntary, but failure to do so will
delay or make it impossible for OPM to pay your alternative annuity lump sum.
Reverse of RI 38-122
Revised August 2010
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