Form Tr-0290 - Application For Acceptance Of Rollover Funds - Tennessee Consolidated Retirement System
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Tennessee Consolidated Retirement System
Prior Service Section
502 Deaderick Street / Nashville, Tennessee 37243-0201
(615) 741-4868 /
APPLICATION FOR ACCEPTANCE OF TRANSFER OR ROLLOVER FUNDS
Instructions —In accordance with T.C.A., Section 8-37-214 and the Internal Revenue Code, a member of the Tennessee
Consolidated Retirement System (TCRS) who is eligible to purchase prior service credit may pay for that additional retirement
credit with a direct transfer or a rollover of a distribution from a retirement plan approved by the IRS under Section 401(a),
401(k) or 403(b) of the Internal Revenue Code. A member may also pay for the additional retirement credit with a rollover of
a distribution from a plan operated by a government under Section 457(b) of the Internal Revenue Code, from a regular IRA
or a Roth IRA. TCRS may NOT accept a transfer or rollover from a 457 plan sponsored by a non-governmental entity.
1. Please review the enclosed brochure Purchasing Prior Service with a Rollover. You may also access the information at
our website /PDFs/PriorServiceRollover.pdf.
2. Complete Part I of this form, have Part II certified by the plan sponsor or IRA trustee and submit it to TCRS with your prior
service payment. A copy of your TCRS prior service billing should also be included.
3. If you are submitting transfer or rollover funds from more than one plan, PART II must be completed for each
plan. Additional forms may be obtained from our web site at /PDFs/tr0290.pdf.
4. It is your responsibility to complete this form for TCRS as well as any other forms required by the investment vendor.
Contact your vendor for those forms and procedures. In addition, it is your responsibility to confirm that the vendor has
completed the TCRS form and transferred appropriate funds.
5. You are prohibited from using the rollover funds as a partial payment. However, rollover funds may be used to pay off
the balance of an established TCRS installment account.
PART I — PRIOR SERVICE PAYMENT PLAN - To be completed by the TCRS member
Name ___________________________________
Social Security Number ______________________________
Address __________________________________________________________________________________________
Street
City
State
Zip
Home Phone _______________________________
Daytime Phone _____________________________________
Total Amount Due
$ ___________________________
Sources of Funding - Summary
1. Transfer or rollover from _________________________________________ $ ___________________________
(Name of Plan or Financial Institution)
2. Transfer or rollover from _________________________________________ $ ___________________________
(Name of Plan or Financial Institution)
3. Transfer or rollover from _________________________________________ $ ___________________________
(Name of Plan or Financial Institution)
4. Personal check (remaining balance, if any, must be paid in lump sum)
$ ___________________________
0.00
TOTAL PAYMENT DUE
$ ___________________________
Signature of Member ___________________________________
Date _______________________________
(Next page to be completed by the plan sponsor or IRA Trustee.)
TR 0290 (Rev. 08/10)
RDA 413
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