Form Tr-0290 - Application For Acceptance Of Rollover Funds - Tennessee Consolidated Retirement System Page 2

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Name _____________________________
Social Security Number ____________________
PART II — VERIFICATION OF SOURCE AND AMOUNT OF DIRECT TRANSFER/
ROLLOVER - To be completed by the plan sponsor or IRA trustee. If more than one
plan is involved, a separate form must be completed for each plan.
TCRS is a qualified plan under Section 401(a) of the Internal Revenue Code.
On __________________, 20______, the _______________________________________________________
(Month/Day)
(Year)
(Name of Plan or Financial Institution)
issued/will issue a distribution or transfer to or on behalf of the individual named on the previous page.
This plan is authorized to issue a transfer or a distribution eligible for rollover to a qualified plan because it is:
Check one
a qualified 401(a) or 401(k) retirement plan sponsored by _____________________________________ ;
a governmental 457 plan sponsored by ___________________________________________________ ;
a 403(b) contract;
a regular IRA established under Section 408 of the Internal Revenue Code. This is not a Roth IRA established
under Section 408A of the Internal Revenue Code or an Education IRA;
a Roth IRA established under Section 408(A) of the Internal Revenue Code; or
a distribution to a beneficiary from a qualified retirement plan.
The total amount of distribution eligible for rollover from this plan is $_________________.
Signature __________________________________
Name (please print) _______________________________
(
)
Title
___________________________________
Phone Number ___________________________________
Name of Employer or Financial Institution _____________________________________________________________
Address _________________________________________________________________________________________
Street
City
State
Zip
Note: Checks should be made payable to “Tennessee Consolidated Retirement System FBO [member’s name and SSN]”.
TR-0290 (Rev. 08/10)
RDA 413

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