Age-Based In-Service Withdrawal Request - Thrift Savings Plan

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THRIFT SAVINGS PLAN
TSP-75
AGE-BASED IN-SERVICE WITHDRAWAL REQUEST
I. INFORMATION ABOUT YOU
1. This request applies to my:
Civilian Account
OR
Uniformed Services Account
2.
Last Name
First Name
Middle Name
/
/
3.
4.
5.
TSP Account Number
Date of Birth (mm/dd/yyyy)
Daytime Phone (Area Code and Number)
Note : If you are married, you must complete either Section VII or VIII on Page 2 depending on your retirement coverage
(see instructions).
II. WITHDRAWAL REQUEST
6. Amount you are requesting:
$
.
OR
Entire vested account balance
,
,
00
(amount must be $1,000 or more)
III. TRANSFER ELECTION
7.
I would like to transfer all or a portion of my withdrawal request to an IRA or eligible employer plan. (Note: You
must include the completed applicable transfer page(s) from this form with your withdrawal request package.)
IV. DIRECT DEPOSIT INFORMATION —
This section is optional. Complete this section if you want the portion of your with­
drawal that is not being transferred (Sections IX – XII) directly deposited into your checking or savings account.
8. Type of Account:
9.
Name of Financial Institution
Checking
10.
11.
Savings
ACH Routing Number (Must be 9 digits)
Checking or Savings Account Number
ADDITIONAL TAX WITHHOLDING —
V.
This section is optional. If you would like more than the mandatory 20% Federal
tax withholding, complete this section. If a portion of your withdrawal is a Required Minimum Distribution, the TSP must
withhold 10% of that portion. Withholding does not apply to amounts transferred to IRAs or eligible employer plans or
which are otherwise nontaxable (see instructions).
.
00
tax:
,
12. In addition to the mandatory 20%, withhold this amount for Federal income
$
VI. CERTIFICATION AND NOTARIZATION —
I certify that the information I have provided on all pages of this withdrawal
request is true and complete to the best of my knowledge. If I did not complete Section VII or VIII on Page 2, I further certify
that I am an unmarried TSP participant. Warning: Any intentional false statement in this application or willful misrepresen­
tation concerning this request is a violation of law that is punishable by a fine or imprisonment for as long as 5 years, or both
(18 U.S.C. 1001).
/
/
13.
14.
Date Signed (mm/dd/yyyy)
Participant’s Signature
15.
Participant’s Address (We will use this address only to notify you if we cannot locate your account based on the information you provided on this form.)
16.
Notary: Please complete the following. No other acknowledgement is acceptable (see instructions). The person
who signed Item 13 is known to or was identified by me and, before me, signed or acknowledged to have signed
this form. In witness thereof, I have signed below on this
day of
,
.
Month
Year
My commission expires:
Notary’s Signature
Date (mm/dd/yyyy)
(
)
[seal]
Notary’s Printed Name
Notary’s Phone Number
Jurisdiction
Do Not Write Below This Line
FORM TSP-75, Page 1 (2/2015)
PREVIOUS EDITIONS OBSOLETE
* P I I S 0 0 2 2 9 9 0 0 2 0 0 0 0 0 0 0 0 P I I S *

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