Notice of Final Deposit and Request for Refund
Retirement Systems of Alabama
PO Box 302150, Montgomery, Alabama 36130-2150
877.517.0020 • 334.517.7000 • www.rsa-al.gov
Your SSN
Name __________________________________________________________________________________________
First Middle/Maiden Last
Address _________________________________________________________________________________________
Street or P.O. Box City State ZIP Code
Telephone Number ___________________________ Email Address _________________________________________
Date of Birth ________________________________
RSA Account Number (if known) ________________________________
Select only one distribution option:
q Lump Sum Payment
I elect to receive (at the above address) full distribution of my account, less the 20% federal income tax withholding required.
q
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/Custodian Information (complete only if Direct Rollover is checked)
Rollover Trustee/Custodian ____________________________________ Account Number __________________________
Contact Person ____________________________________________ Telephone Number ________________________
Address _________________________________________________________________________________________
Street or P.O. Box City State ZIP Code
Type of account into which money will be transferred: (An Education IRA is not an eligible plan)
q 401 Qualified Retirement Plan q 403(a) Annuity Contracts q 403(b) Tax Sheltered Annuity q Roth IRA
q 408(a) Individual Retirement Account q 408(b) Individual Retirement Annuity q Governmental Deferred Compensation Plans
(Traditional IRA) (IRC 457)
Plan accepts non-taxable funds? q Yes q No
Trustee/Custodian Official Signature ____________________________________________ Date ___________________
Signature by Trustee/Custodian 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.
Your Signature ______________________________________________________ Date __________________________
State of ___________________________________ , County of ________________________________
I, ________________________________________ , a Notary Public, hereby certify that the above named individual whose name
is signed to the foregoing document, personally appeared before me and acknowledged under oath that the statements made are
true. Given under my hand this _________________ day of __________________________________________ , 20 ________ .
Seal
Signature of Notary Public ___________________________________________
My Commission Expires _____________________________________________
Your
Information
Distribution
Information
Sign Here è
Trustee/Custodian
Read the enclosed
special tax notice
before completing the
remainder of this form.
Check One: q TRS q ERS q JRF q SNU Supernumerary members only q MRS City of Montgomery Plan Employees
RSA_7
page 1 of 2
REV 03-2021
Rollover Trustee/
Custodian Information
requires the signature
from the Rollover
Trustee/Custodian
Official.
Sign Here è
Member
Signature
Certification
Please have your signature
acknowledged before a
Notary Public.
