Form Hr 16 - Orp/tda Transfer Verification Form Page 2
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2From:__________________________________________________________________________________________________
Name of surrendering vendor
To:_____________________________________________________________________________________________________
Name and address of receiving vendor
According to IRS regulations, transfers must be contract to contract exchanges and the transferred funds must continue to be
subject to the same, or more stringent, early distribution rules.
B. EMPLOYEE SIGNATURE
I understand that the account(s) I am transferring may be subject to surrender charges, contingent deferred sales charges or other fees
from the surrendering vendor. I authorize the surrendering vendor to liquidate my account if liquidation of investments is necessary
and transfer the assets and any subsequent funds that may be received for deposit in this account as described above.
I understand that I bear the risk of the performance of the product(s) I select, that The Texas A&M University System has no fiduciary
responsibilities in this area, and that The Texas A&M University System is not liable for any tax consequences occurring under these
programs.
_________________________________________________________________
___________________________________
Employee signature
Date
C. RECEIVING VENDOR INFORMATION (required if using individual vendor representative)
_____________________________________________
_________________________________________________________
Name of Representative
Company
_______________________________
_______________________________
_______________________________
Telephone number
Fax number
E-mail address
D. TO BE COMPLETED BY YOUR SYSTEM MEMBER HUMAN RESOURCES OR PAYROLL OFFICE
I hereby certify that the receiving vendor named above is an active A&M System ORP and/or TDA vendor and the receiving
representative is an authorized vendor representative; thus the requested fund transfer may be completed. I also certify that the
above employee
does or
does not have a vested interest in the state’ s matching contribution.
This application is being returned for the following reason(s):
The receiving vendor named above is not an active A&M System ORP and/or TDA vendor.
The receiving representative is not an authorized ORP and/or TDA vendor representative.
A&M System-Authorized Representative: Make a copy and forward (including receiving vendor’ s transfer request form) directly to
surrendering vendor.
____________________________________________________
_________________________________ ____________
Name and title
Signature
Date
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