Age-Based In-Service Withdrawal Request - Thrift Savings Plan Page 3
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1
2
3
4Name:
TSP Account Number:
(Last, First, Middle)
TRANSFER — TRADITIONAL
You and the IRA trustee or plan administrator must complete this page if you checked the box in Item 7 and you want to transfer
all or a part of the traditional (non-Roth) portion of your withdrawal to a traditional IRA, eligible employer plan, or a Roth IRA. Your
traditional TSP balance consists of traditional contributions, taxexempt contributions, all agency contributions, and the earnings
associated with these contributions. Note: If you choose to transfer the traditional portion of your withdrawal to a Roth IRA, you
will have to pay tax on that portion when you file your tax return for the year.
IX. YOUR TRANSFER ELECTION FOR TRADITIONAL BALANCE —
After you complete this section, take or send this page
(including the instructions on the back) to your IRA or plan. Your IRA trustee or plan administrator must complete Section
X. You must submit the completed package in order for your transfer to be processed.
.
29. Transfer
0% of the traditional (non-Roth) portion of my withdrawal to the IRA or plan identified in Section X.
Note: You must also complete Section III on Page 1.
X. TRANSFER INFORMATION FOR TRADITIONAL BALANCE —
This section is to be completed by the IRA trustee or plan
administrator. The account described here must be a traditional IRA, eligible employer plan, or a Roth IRA. Please return
this completed form to the participant. Do not submit transfer forms of financial institutions or plans.
30.
Eligible Employer Plan
Type of Account:
Roth IRA
Traditional IRA
31.
IRA/Plan Account Number or Other Customer ID
32.
Check this box if taxexempt balances are accepted into the account identified above.
33. Provide the name and mailing address information below exactly as it should appear on the front of the check.
}
The financial
institution
Make check payable to
or plan will
need to use
this information
to identify the
account that
will receive
the transfer.
–
Zip Code
City
State
I confirm the accuracy of the information in this section and the identity of the individual named above. As a representative of
the fi nancial institution or plan to which the funds are being transferred, I certify that the financial institution or plan agrees to
accept the funds directly from the Thrift Savings Plan and deposit them into the IRA or eligible employer plan identified above.
34.
(
)
Daytime Phone (Area Code and Number)
Typed or Printed Name of Certifying Representative (Last, First, Middle)
/
/
35.
36.
Signature of Certifying Representative
Date Signed (mm/dd/yyyy)
Do Not Write Below This Line
Form TSP-75, Page 3 (2/2015)
PREVIOUS EDITIONS OBSOLETE
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