Form Rsa 7 - Notice Of Final Deposit And Request For Refund - Alabama
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2N
F
D
R
R
RSA 7
OTICE OF
INAL
EPOSIT AND
EQUEST FOR
EFUND
Check One:
09/14
Retirement Systems of Alabama
ERS
P. O. Box 302150 Montgomery, AL 36130-2150
TRS
334-517-7000 or 877-517-0020
JRF
See reverse side for P
III and instructions.
ART
Please type or print using black ink.
P
I M
I
ART
EMBER
NFORMATION
Name:
Date of Birth:
/
/
First
Middle
Last
Maiden
Social Security No.:
-
-
Home Phone Number: (
)
Address:
Work Phone Number: (
)
Street Address or P. O. Box
RSA Account Number:
_________________________
(If known)
City
State
Zip
P
D
O
(Please read the enclosed special tax notice before completing the remainder of this form.)
ART II
ISTRIBUTION
PTION
Please check either Part A or Part B:
Part A. Lump Sum Payment: I elect to receive (at the above address) full distribution of my account, less the 20% Federal Income
Tax withholding required.
Part B. Direct Rollover: I elect to have
% of the taxable benefit transferred directly to the trustee named below (for
transfers less than 100%, the remainder of the account, less the mandatory 20% Federal Income Tax withholding will be
paid to me at the above address).
Rollover Trustee Information (complete only if Part B is checked): Requires Rollover trustee official’s signature
Rollover Trustee Name:
Account Number:
_______
Contact Person:
Phone No.: (
)
Address:
Street Address or P. O. Box
City
State
Zip
Type of account into which money will be transferred:
401 Qualified Retirement Plan
403(a) Annuity Contracts
403(b) Tax Sheltered Annuity
408(a) Individual Retirement Account
408(b) Individual Retirement Annuity
Governmental Deferred
Roth IRA
Compensation Plans (IRC 457)
An Education IRA is not an eligible plan.
Plan does not accept non-taxable funds.
Plan accepts non-taxable funds.
Signature of Rollover Trustee Official
Date
Signature by trustee official affirms acceptance of transfer
I certify that I have received the printed explanation entitled Special Tax Notice Regarding Your Rollover Options prior to
signing this certification. I also certify that I have read the Employment Termination Statement on the back of this form.
Signature
Date
S
, C
TATE OF
OUNTY OF
On this
day of
, 20
before me, the undersigned authority, a
Notary Public in and for said County and State, personally appeared before me, the above named individual, known to me to be the
person who subscribed to the foregoing instrument.
Signature of Notary Public
Seal
My Commission Expires
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