Age-Based In-Service Withdrawal Request - Thrift Savings Plan Page 4
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1
2
3
4Name:
TSP Account Number:
(Last, First, Middle)
TRANSFER — ROTH
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 Roth portion of your withdrawal to a Roth IRA or to a Roth account maintained by an eligible employer plan.
Your Roth TSP balance consists of any employee contributions that you designated as Roth when you made your contribution
election and the earnings associated with these contributions. Withdrawals of Roth contributions are paid taxfree. The earnings
associated with these contributions are paid taxfree only if 5 years have passed since January 1 of the calendar year in which you
made your first Roth contribution and you have reached age 59½ or have a permanent disability. (See instructions.)
XI. YOUR TRANSFER ELECTION FOR ROTH BALANCE —
After you complete this section, take or send this page (includ
ing the instructions on the back) to your IRA or plan. Your IRA trustee or plan administrator must complete Section XII.
You must submit the completed package in order for your transfer to be processed.
37. Transfer
.0% of the Roth portion of my withdrawal to the IRA or plan identified in Section XII. Note: You must
also complete Section III on Page 1.
XII. TRANSFER INFORMATION FOR ROTH BALANCE —
This section is to be completed by the IRA trustee or plan admin-
istrator. The account described here must be a Roth IRA or a Roth account maintained by an eligible employer plan. Please
return this completed form to the participant. Do not submit transfer forms of financial institutions or plans.
Eligible Employer Plan — Roth Account
38.
Type of Account:
Roth IRA
39.
IRA/Plan Account Number or Other Customer ID
40. 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.
(
)
41.
Daytime Phone (Area Code and Number)
Typed or Printed Name of Certifying Representative (Last, First, Middle)
/
/
42.
43.
Date Signed (mm/dd/yyyy)
Signature of Certifying Representative
Do Not Write Below This Line
Form TSP-75, Page 4 (2/2015)
PREVIOUS EDITIONS OBSOLETE
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