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ICMA-RC • Attn: Workow Management Team • P.O. Box 96220 • Washington, DC 20090-6220 • Toll Free 800-669-7400/for 403(b) plans 833-438-4032 • www.icmarc.org • Fax 202-682-6439
40082-0619-331
1
Personal
Information
2
Transfer To
I want to transfer assets to my ICMA-RC Plan: (Check only one box. Each transfer requires a separate form.)
457(b) Plan Account Number: 3 0 _________ Employer Plan Name ___________________________________________
401(a) Plan Account Number: 1 0 _________ Employer Plan Name ___________________________________________
401(k) Plan Account Number: 1 0 _________ Employer Plan Name ___________________________________________
403(b) Plan Account Number: 4 0 _________ Employer Plan Name ___________________________________________
*Must be completed – lack of provider information may delay your transfer request.
I am requesting a direct rollover from the account specied below.
457(b) plan 401(a) plan 401(k) plan 403(b) plan Traditional IRA Roth Assets Other: ________________
Plan Provider Name: _____________________________________________________________________________
Eligible Employer Plan (if applicable): ______________________________________________________________
Plan Provider Phone Number:
( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___
Plan Provider Address: _____________________________________________________________________________
City* _____________________________________________ State* ____ ____ Zip Code*
____ ____ ____ ____ ____ - ____ ____ ____ ____
Participant Account Number: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Does your provider require a Letter of Acceptance?
Yes No
3
Transfer From
(Other
Provider
Account
Information)
3a
Transfer
Amount
(must be
completed)
Direct Rollover/Transfer To ICMA-RC Form - Page 1 of 3
Please conrm that your 457(b), 401(a), 401(k), or 403(b) plan permits roll-ins of Roth assets prior to requesting a rollover.
Note: Other after-tax assets are not eligible for a rollover into a 457(b) plan.
I wish to liquidate and transfer:
100% of my account balance. Estimated Transfer Amount $ ___________________. OR
Partial transfer in the amount of $_______________________.
Note: If the recipient plan specied in Section 2 of this form is not able to accept a rollover of Roth or other after-tax assets, these
amounts will be distributed to you, or you can establish a Roth IRA with ICMA-RC. Similarly, other after-tax assets will be returned to you
if received.
__________% Specify an alternate percentage if you want your current provider to distribute less than 100% of your Roth assets.
Note to Transferring Financial Organization – If the transfer includes Roth assets or other after-tax assets, please note
the following on the check/wire: 1) the amount of Roth or other after-tax contributions, 2) the amount attributable to earnings on the Roth
or other after-tax contributions, and 3) the date of the participant’s rst Roth contribution (if applicable). For transfers to a 457(b) plan,
the amount of non-457(b) rollover assets subject to early withdrawal penalty, (if any) should be noted.
(EXTERNAL)
Roth or
Other
After-Tax
Assets
Marital Status
Married Single
Full Name of Participant
Last First M.I.
___________________________________________________________________
Social Security Number (for tax reporting purposes)
______ - _____ - ____________
Date of Birth
Month Day Year
Preferred Phone Number
Area Code
_____ / _____ / __________
( ________ ) ________ - ______________
Mailing Address/Street
City
State
Zip Code
___________________________________________________________________
___________________________________________________________
_____ ______________
Email
____________________________________
Check this box
if there are any
changes. If you
have more than
one ICMA-RC
account, any
change will be
made across all
of your accounts.
• You must be enrolled in your employer plan prior to submitting this form. If you are not sure contact your Retirement Plan Specialist.
• Conrm with your provider what is needed to liquidate your assets.
• If you are taking receipt of your rollover check and/or Roth Assets, attach a copy of the Letter of Acceptance from ICMA-RC and a statement from your provider
that displays your contribution types.
• Please print legibly in blue or black ink. The Direct Rollover/Transfer form must be completed in its entirety.
• If your provider requires the original Direct Rollover/Transfer form do not fax. Mail to the address located at the bottom of the form.
