Form Orp-3 - Optional Retirement Program Of The University Of North Carolina Acknowledgement Of Particpation Page 4
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OPTIONAL RETIREMENT PROGRAM OF THE UNIVERSITY OF NORTH CAROLINA
ORP-3
ACKNOWLEDGEMENT OF PARTICPATION
SECTION A. EMPLOYEE DATA
FIRST NAME
MI
LAST NAME
MAILING ADDRESS
SOC. SEC NO.
CITY
STATE
ZIP CODE
TELEPHONE NO.
EMAIL ADDRESS
UNC EMPLOYING INSTITUTION (YOUR CAMPUS NAME)
EMPLOYMENT TERMINATION DATE
SECTION B. RETIREMENT PLAN PARTICIPATION
UNC ORP PARTICIPATION (SELECT ALL THAT APPLY)
DATES OF UNC ORP PARTICIPATION
FIDELITY
LINCOLN
TIAA-CREF
VALIC
FROM
TO
OTHER NORTH CAROLINA RETIREMENT PLAN MEMBERSHIP
DATES OF OTHER NORTH CAROLINA RETIREMENT PLAN MEMBERSHIP
TSERS
LGERS
CJRS
FROM
TO
SECTION C. REASON FOR TERMINATION
RETIREMENT
RETIREMENT EFFECTIVE DATE
Vested participants in the UNC ORP may be eligible to continue group health insurance coverage as a retiree under the State Health Plan
of North Carolina. To be eligible for group health insurance you must be receiving a monthly retirement benefit under the UNC ORP. If
you withdraw, transfer or roll over your UNC ORP contributions to an IRA or another employer’s retirement plan, you will forfeit your
right to the State’s retiree group health plan coverage.
TRANSFER TO ANOTHER UNC CAMPUS
COMPLETE THIS SECTION IF YOU ARE TRANSFERING TO ANOTHER UNIVERSITY OF NORTH CAROLINA INSTITUTION
NAME OF NEW CAMPUS:
_______
EMPLOYMENT EFFECTIVE DATE:_____________________________________________________________
NEW JOB OPPORTUNITY & OTHER REASON
(SELECT ONLY ONE)
NOT CONTINUING PARTICIPATION IN A “LIKE” RETIREMENT PLAN
DELAYED NOTIFICATION OF ENROLLMENT IN A “LIKE” RETIREMENT PLAN
CONTINUING PARTICIPATION IN A “LIKE” RETIREMENT PLAN AT ANOTHER INSTITUTION
(PROVIDE INFORMATION BELOW)
NAME OF NEW INSTIUTION:_______________________________________________________________
EMPLOYMENT EFFECTIVE DATE:____________________________________________________________
MAILING ADDRESS OF NEW INSTITUTION:____________________________________________________
“Like” Retirement Plan means a retirement plan of an institution, organization or system of higher education or health care, including
without limitation, schools which are part of the National Consortium for Specialized Secondary Schools of Mathematics, Science and
Technology.
ORP PARTICIPANT AUTHORIZATION AND ACKNOWLEDGEMENT
I acknowledge that I have read the UNC Optional Retirement Program Disclosure Notice and understand that if I am deemed “not
vested” in the University contribution, I forfeit all rights to the University portion in my UNC ORP account and the portion of my account
that represents my contributions may be retained in the insurance/mutual fund contract or withdrawn/rolled over to me as permitted
by such contract.
PARTICIPANT SIGNATURE:
DATE:
/
/
Form ORP-3 (Rev. 11/12)
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