Rev. 02/10
State of _______________ City/County of _______________
DEFERRED RETIREMENT OPTION PROGRAM
(DROP) ACCOUNT DISTRIBUTION ELECTION
please type or print in ink
Date:
Check Date:Check Amount:
Check Number:
ID Verified
RRS USE ONLY
Rollover Instructions Received (if applicable)
Member/Designated Beneficiary Signature
PART B: ACCOUNT DISBURSEMENT ELECTION
PART C: NOTARY PUBLIC
DROP Exit Date
I elect to receive payment of the DROP benefits via direct rollover, paid
directly from the DROP to the custodian of an eligible retirement plan as
defined in section 401(a), 401(k), 403(b) or 457 of the Internal Revenue
Service Code, a traditional individual retirement account (IRA) or an
individual retirement annuity. (NOTE: Rollover instructions must be provided
from the qualified plan.)
I elect to receive payment of the DROP benefits in a lump sum, less all
applicable federal and state withholding taxes.
Date
PART A: MEMBER INFORMATION
Name:
SSN:
Birth Date:
Address:
I ACKNOWLEDGE THAT I AM AWARE OF THE TAX CONSEQUENCES
OF MY ELECTION, AND THAT THIS ELECTION IS IRREVOCABLE AND
CANNOT BE CHANGED.
Prepared by:
Date:
Reviewed by:
Notary Registration Number _____________________
Member/Designated Beneficiary Printed
The foregoing instrument was acknowledged before me this _____ day of __________, 20 _____ by
_____________________________________________ (name of person seeking acknowlegment)
Notary Signature ______________________________
My Commission Expires ________________________
900 East Broad Street
Room 400
Richmond, VA 23219
RICHMOND RETIREMENT SYSTEM
www.richmondgov.com/retirement
Phone 804.646.5958
Fax 804.646.5299
