Form Dc-3722-0911 - Direct Transfer For Purchase Of Permissive Service Credits - Nationwide Retirement Solutions

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Direct Transfer for Purchase of Permissive
Service Credits
Nationwide Retirement Solutions
All the information on this document must be completed and returned to:
205 W. Randolph St., Suite 1540
Chicago, IL 60606
1-855-457-2489
PARTICIPANT INFORMATION:
Name: __________________________________________________
SSN or Account Number: ____________________
Home Address: ______________________________________________________________________________________
Street
City
State
Zip Code
Telephone Number: Work ________________________________
Home ______________________________________
(Area Code)
(Area Code)
PLAN TRANSFER FROM:
q City of Chicago Deferred Compensation Plan (0035044001)
q Cook County Forest Preserve Deferred Comp. Plan (0035043001)
q Cook County Employees Deferred Compensation
q Other ______________________________________
Plan (0035046001)
In accordance with the provisions of the Economic Growth and Tax Relief Reconciliation Act of 2001, your plan
has elected to allow the use of all or a portion of a 457 Deferred Compensation Plan account balance to pur-
chase permissive service credits or for the repayment of service credits to a governmental defined benefit (pen-
sion) plan (as defined in IRC Section 414(d)).
PENSION FUND VERIFICATION:
Please consider this as confirmation of the balance due of $_______________ if paid by ____________.
Payments made and balances due after this date may accrue additional interest.
Pension Board Authorized Signature
__________________________________ Date ______________
(The individual signing this request must be an authorized signer of the appropriate pension board and acknowledges that the pension
board, as checked below, will accept this request for the benefit of the participant from a Section 457 Deferred Compensation Plan.)
q
q
Municipal Employees' Annuity and Benefit Fund of Chicago
State Universities Retirement Systems
1901 Fox Drive, Champaign, IL 61820
321 N. Clark Street, Suite 700, Chicago, IL 60654-4767
800/ASK-SURS (800/275-7877)
312/236-4700
q
q
State Retirement Systems
Policemen's Annuity and Benefit Fund of Chicago
2101 South Veterans Pky, PO Box 19255
221 N. LaSalle St., Suite 1626, Chicago, IL 60601-1203
Springfield, IL 62794-9255
312/744-3891
217/785-7444
q
Laborers' and Retirement Board Employees' Annuity and
q
Benefit Fund of Chicago
Park Employees’ Annuity & Benefit Fund of Chicago
55 E. Monroe St., Suite 2720, Chicago, IL 60603
321 N. Clark Street, Suite 1300, Chicago, IL 60654-4739
312/553-9265
312/236-2065
q
Public School Teachers’ Pension & Ret. Fund of Chicago
q
Firemen's Annuity and Benefit Fund of Chicago
203 N. LaSalle St., Suite 2600, Chicago, IL 60601
20 S. Clark St., Suite 1400, Chicago, IL 60603
312/641-4464
312/726-5823
q
q
Other __________________________________________
Illinois Municipal Retirement Fund
______________________________________________
2211 York Road, Suite 500, Oak Brook, IL 60523-2337
______________________________________________
800/275-4673
Participant understands that to effect this transfer, investment options will be liquidated in the order established by the plan
sponsor. Transfer requests must be authorized by the appropriate pension board and received by Nationwide
Retirement Solutions by the 15th of the month to be processed by the end of the month. The Plan Sponsor and its
Third-Party Administrator assumes no responsibility for any investment losses the participant may experience as a result of
this transfer or attempt to transfer. By making said transfer on behalf of participant, Plan Sponsor and its Third-Party
Administrator make no warranties or representations as to whether any such transfer will be constructed as a taxable event
or whether receiving plan may lawfully accept such transfers.
Participant Signature:
__________________________________________________
Date: ______________________
Registered Principal Signature:
__________________________________________
Date: ______________________
Original and Copy 2 - NRS
Copy 3 - Pension Board
Copy 4 - Participant
DC-3722-0911

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