Form Td22 - Tda Direct Rollover Election Form Page 4
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2
3
4CONTINUED FROM PAGE 3
PROGRAM #1
Name of Firm (check will be made payable to)
Type of Program (Check only one below)
IRA
Section 401(k) Plan
Name of Account
Account Number
Address
City
State
Zip Code
PROGRAM #2
Name of Firm (check will be made payable to)
Type of Program (Check only one below)
IRA
Section 401(k) Plan
Name of Account
Account Number
Address
City
State
Zip Code
PROGRAM #3 (You may complete this section only if you elected #2 in Part D of your “TDA Withdrawal Application” or
“TDA Withdrawal Application for Beneficiaries.”)
Name of Firm (check will be made payable to)
Type of Program (Check only one below)
IRA
Section 401(k) Plan
Name of Account
Account Number
Address
City
State
Zip Code
PART D: Please read the following and sign and date below.
I certify that I have read the information on pages 1 and 2 of this form.
I certify that, to the best of my knowledge, the successor program(s) named above is qualified to receive this Direct Rollover
under the applicable provisions of the Internal Revenue Code. I acknowledge that such certification is provided as a basis for TRS’
reasonable reliance on same.
SIGNATURE ________________________________________________________ DATE (M/D/Y) ____________________
THIS FORM CANNOT BE PROCESSED UNLESS IT IS FILED WITH YOUR CORRECTLY COMPLETED
“TDA WITHDRAWAL APPLICATION” OR “TDA WITHDRAWAL APPLICATION FOR BENEFICIARIES.”
PAGE 4
TD22 (12/13)
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