Fillable Form Hr 16 - Orp/tda Transfer Verification Form printable pdf download

CLEAR FIELDS PRINT FORM

The T

The Texas A&M University System

exas A&M University System

HR 16 (7/06)

ORP/TDA T

ransfer V

erification For

erification Form m m m m

erification For

ORP/TDA T

ORP/TDA Transfer V

ransfer V

ransfer Verification For

erification For

With few exceptions, you have the right to request, receive, review and correct information about yourself collected using this form.

_____________________________________________________________ ___________________________________

Name (Print)

Social Security number

_____________________________________________

_______________________________

____________________

System member name

Office phone

Date

INSTRUCTIONS

Complete Section A as appropriate, then sign Section B.

Complete information about receiving vendor representative in Section C. (Required if using individual vendor representative)

Attach receiving vendor’ s transfer request.

Make a copy for your records.

Return to your System member Human Resources or Payroll office.

A. TRANSFER INSTRUCTIONS

(check all that apply)

I authorize a:

Full transfer of: ORP

Regular TDA

Roth TDA

account(s).*

Partial transfer of: ORP

Regular TDA

Roth TDA

account(s).

* Please note: The surrendering vendor will close your account based on your request for a full transfer; therefore, the ORP Salary Reduction

Acknowledgment/Change of Vendor Form (HR 14) and/or TDA Salary Reduction Agreement/Change of Vendor Form (HR 17) must be completed

in order to direct future payroll contributions to the new/receiving vendor.

For full transfers

full transfers

full transfers, indicate only the contract or account number. For par

par

partial transfers

par

tial transfers

tial transfers, also indicate the dollar amount or percent of

total to be transferred.

ORP Contract or Account # _______________________________________

Investment Option/Fund Name_____________________________________