Fillable TRANSFER FROM ICMA-RC TO ICMA-RC FORM CHECKLIST (City of Riverside, California)

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TRANSFER FROM ICMA-RC TO ICMA-RC FORM CHECKLIST (City of Riverside, California)

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The TRANSFER FROM ICMA-RC TO ICMA-RC FORM CHECKLIST (City of Riverside, California) form is 3 pages long and contains:

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  • 10 check-boxes
  • 39 other fields

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File type: PDF

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COMPLETING THE FORM
SECTION 1 – YOUR PERSONAL INFORMATION (MUST BE COMPLETED)
£ Make sure you are enrolled in the plan.
SECTION 2 – TRANSFER TO (MUST BE COMPLETED)
£ Indicate the ICMA-RC account that you are transferring the
assets to, and provide the employer plan name. (Only One Box
Should Be Checked)
SECTION 3 – TRANSFER FROM (MUST BE COMPLETED)
£ Indicate the ICMA-RC account that you are transferring the
assets from, and provide the employer plan name. (Only One
Box Should Be Checked)
SECTION 4a – TRANSFER AMOUNT
£ Indicate whether you wish to transfer the total value of your
account (100%) or a specied portion of the account. If you elect
to transfer a portion of your account, specify the dollar amount.
If you are requesting the funds from a specic fund, please
indicate the fund name and dollar amount.
SECTION 4b – ROTH OR OTHER AFTER-TAX ASSETS
£ If the recipient plan specied 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, unless you request that these
amount not be transferred by checking the applicable box in this
section and writing “0” in the space provided.
£ Please conrm that your 457 or 401(k) plan permits roll-ins of
Roth assets prior to requesting a rollover. Note that other after-
tax assets are not eligible for a rollover into a 457.
SECTION 5 – ROLLOVER INVESTMENT ALLOCATION
£ Please read this section carefully. It contains detailed
information on how the assets you transfer to your ICMA-RC
account will be invested.
£ Note to participants in 457 plans residing in New York
State: Your assets will be invested according to the allocation
instructions on le for your current contributions.
SECTION 6 – PARTICIPANT AND EMPLOYER SIGNATURES
£ Please sign the form and obtain your termination date and an
authorized signature from your previous employer (for the plan
specied in Section 3).
£ e employer signature and termination date is required in order
to process your transfer request, unless your previous employer
has already notied ICMA-RC of your separation from service.
Mail or fax completed forms to ICMA-RC. If you fax the form,
please do not mail the original.
Mail: Fax:
ICMA-RC ICMA-RC
ATTN: Workow Management ATTN: Workow Management
Tea m Te am
P.O. Box 96220 202-682-6439
Washington, DC 20090-6220
Qualied Joint and Survivor Annuity (applies to
married participants in some 401 plans only)
If you are married and transferring assets from an ICMA-RC 401
plan, and the employer sponsoring the plan has elected the
Qualied Joint and Survivor Annuity Option, your spouse must
consent to the transfer of assets to another retirement plan. You
and your spouse will need to complete the Waiver of Qualied
Joint and Survivor Annuity Form available online at www.icmarc.
org/forms.
VantageTrust Retirement IncomeAdvantage Fund
If your plan oers the VantageTrust Retirement IncomeAdvantage
Fund (the Fund), any assets you have invested in the Fund will
be excluded from your transfer/rollover request. If you would
like to consolidate your Fund balances into one ICMA-RC plan,
please contact ICMA-RC for the appropriate transfer form. You
can do a fund transfer from the Fund to other investment options
available in your plan if you would like to have the Fund assets
distributed with your transfer/rollover request. However, you
should be aware that withdrawals from the Fund prior to Lock-In
proportionately reduce your guaranteed values. After Lock-In,
Excess Withdrawals will proportionately reduce and potentially
terminate available guarantees. Please note that if you withdraw
all of your assets from the Fund, you lose all guarantees. For
additional information, please review the VantageTrust Retirement
IncomeAdvantage Fund Important Considerations document.
TRANSFER FROM ICMA-RC TO ICMA-RC FORM CHECKLIST
Use the below Checklist to help you complete the form on the following pages so that we can process
your transfer of ICMA-RC’s assets.
By providing all the necessary information, we can avoid delays and take care of your request
as soon as possible!
ICMA-RC • Attn: Workow Management Team • P.O. Box 96220 • Washington, DC 20090-6220 • Toll Free 800-669-7400 • www.icmarc.org • Fax 202-682-6439
1
Transfer From ICMA-RC To ICMA-RC Form - Page 1 of 2
• Use this form to request a direct rollover/transfer of assets from one ICMA-RC plan to another ICMA-RC plan. Do not use this form to request a transfer to a Vantagepoint IRA.
• If you are new to the ICMA-RC plan you are transferring into, you must also complete the appropriate enrollment form.
1
Personal
Information
2
Transfer To
I want to transfer assets from my ICMA-RC: (Check only one box. Each transfer requires a separate form.)
457 Plan Account Number: 3 0 _________ Employer Plan Name _______________________________________________
401 Plan Account Number: 1 0 _________ Employer Plan Name _______________________________________________
Existing Vantagepoint IRA Account Number: 7 0 ________________
3
Transfer
From
I wish to liquidate and transfer:
My entire account OR The following portion of my account in the manner specied below:
Fund Name Dollar Amount Fund Name Dollar Amount
1) ______________________________________ _____________ 3) ________________________________________ _____________
2) ______________________________________ _____________ 4) ________________________________________ _____________
Note that if the recipient plan specied 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, unless you request that these amounts not be transferred.
________% Check this box and specify an alternate percentage if you want less than 100% of your Roth and/or other after-tax assets
transferred/distributed with your request (if applicable).
Please conrm that your 457 or 401(k) plan permits roll-ins of Roth assets prior to requesting a rollover. Note that other after-tax assets are
not eligible for a rollover into a 457 plan.
4a
Transfer
Amount
5
Rollover
Investment
Allocation
ICMA-RC • P.O. Box 96220 • Washington, DC 20090-6220 • Toll Free 800-669-7400 • www.icmarc.org • Fax 202-682-6439
(INTERNAL)
4b
Roth or
Other
After-Tax
Assets
Assets will be invested in your account according to your rollover allocation instructions. You can provide or conrm your rollover investment
allocation by accessing your account online at www.icmarc.org and select the “Manage My Account” tab and the “Future Allocations”
menu option or by contacting ICMA-RC. Read below for information on how rollover assets will be invested in the absence of valid rollover
allocation instructions.
457 Plan: In the absence of valid rollover allocation instructions, assets will be invested according to the allocation instructions for
contributions to your account (or to the default fund selected by your employer, if you have not yet provided allocation instructions for the
investment of contributions to your account).
New York State 457 Deferred Compensation Plan: If your 457 plan account is with an employer in New York State, the transferred
assets will be invested according to the same allocation instructions that are used for the investment of contributions to your account (or to
the default fund selected by your employer, if you have not yet provided allocation instructions for the investment of contributions to your
account).
401 Plan: In the absence of valid rollover allocation instructions, assets will be invested in the default fund selected by your employer.
ICMA-RC will send you a conrmation notice when the transferred assets have been received and credited to your account. You will have the
ability to transfer your assets to any investments available within your plan at any time by accessing your account online at www.icmarc.org
or by contacting ICMA-RC.
36271-0118-W1807
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
Daytime Phone Number
Area Code
_____ / _____ / __________
( ________ ) ________ - ______________
Mailing Address/Street
City
State
Zip Code
___________________________________________________________________
___________________________________________________________
_____ ______________
Email
____________________________________
I want to transfer assets to my ICMA-RC: (Check only one box. Each transfer requires a separate form.)
457 Plan Account Number: 3 0 _________ Employer Plan Name _______________________________________________
401 Plan Account Number: 1 0 _________ Employer Plan Name _______________________________________________
2
Transfer From ICMA-RC To ICMA-RC Form - Page 2 of 2
I acknowledge that I have read and agree to the disclosures shown in the instructions for this section. I have also read and agree to the
process described in Section 5 of this form relating to how the transferred assets will be invested within my account.
I authorize and request ICMA-RC to liquidate the retirement plan account specied in Section 3 and transfer it to the ICMA-RC retirement
plan account specied in Section 2.
_______________________________________________________________________ ____ ____ /____ ____ /____ ____ ____ ____
Employee Signature
By signing, the employer conrms the participant is eligible to transfer assets from the retirement plan specied in section 3. A signature is
not required if the employer has already notied ICMA-RC of the participant’s separation from service.
_________________________________________________________________________ ____ ____ /____ ____ /____ ____ ____ ____
Authorized Employer Ofcial’s Signature
_________________________________________________________________________
Name and Title of Authorized Ofcial (Please Print)
Participant’s Termination Date ____ ____ /____ ____ /____ ____ ____ ____ Vesting ____________________ %
6
Participant
and
Employer
Signatures
ICMA-RC • P.O. Box 96220 • Washington, DC 20090-6220 • Toll Free 800-669-7400 • www.icmarc.org • Fax 202-682-6439
(INTERNAL)
Month Day Year
Month Day Year
Month Day Year
Employer Plan Number
Social Security Number
______ - _____ - ____________
___________________
36271-0118-W1807
ICMA RETIREMENT CORPORATION
P.O. BOX 96220
WASHINGTON, DC 20090-6220
800-669-7400
WWW.ICMARC.ORG
36271-0118-W1807
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TRANSFER FROM ICMA-RC TO ICMA-RC FORM CHECKLIST (City of Riverside, California)

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Completed 4 August 2020

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