Fillable Rollover - NPERS3605 Withholding Certificate

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Rollover - NPERS3605 Withholding Certificate

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Country of origin: US
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NPERS3101
Rev. 11/2019
Page 1 of 1
BAR CODE
Last First Middle
Name
Date of Birth - -
Plan Type
(Check all
that apply.)
Email Address
School
Patrol
State
County
DCP
DROP
Address City State Zip
Rollover to Financial Institution
This form is required in order for NPERS to process a rollover. A separate form is required for each rollover/transfer
or if you would like your pre and post-tax money to go to separate accounts.
Section 1:
This section is to be completed by the Member
I have reviewed this form and I direct NPERS to roll my funds as directed on the Request for Distribution form to the
financial institution named in section 2.
Member Signature__________________________________________________________Date___________________
Section 2:
This section is to be completed by the receiving financial institution
Financial Institution Account Information
(Please Check the appropriate box)
Traditional IRA
Roth IRA
Qualified Plan
Financial Institution Account Number (optional)
_______________________________
Anticipated Amount:
$______________________OR _____________________%
Financial Institution Information
Make Payable To (Financial Institution Name):
____________________________________________
Financial Institution Address:
______________________________________________
______________________________________________
______________________________________________
“FBO Member Name” is automatically included.
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Rollover - NPERS3605 Withholding Certificate

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Completed 7 April 2020

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