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TSA Consulting Group, Inc. Transaction Information Form Instructions:

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TSA Consulting Group, Inc.
Transaction Information Form
Instructions: This form is intended as a supplement to your Investment Provider’s paperwork.
Please check if ORP
1
I am requesting a Distribution from my 403(b)/457(b)/401(a) account with__________________________________
(Company Name)
Distribution Type: Cash Distribution 403(b) Financial Hardship Withdrawal 457(b) Unforeseen Emergency Distribution
Return of Excess Contribution
I am requesting a
Rollover 403(b) Contract Exchange/457(b) Transfer Employer-to-Employer Transfer Purchase of Service Credit Transfer
from ________________________________________________ to ________________________________________________
(Outgoing Company Name) (Receiving Company Name)
Qualifying event:
Age Eligible Separation of Service * - Date of Separation: ____/____/____ Death Claim
(*cannot currently be re-employed)
Qualified Domestic Relations Order (QDRO)
I am requesting a loan:
General Loan Residential Loan
Page 1 of 2
Important Note to Participant
Please retain a copy of this form as well as a copy of all original
documents submitted for your records. All documents received by
TSACG for the requested transaction will be forwarded to the
Investment Provider listed. If no selection is made, all documents will be
forwarded to the appropriate Investment Provider company.
NOTE: Documents will not be returned to the participant.
There may be tax consequences for the requested transaction. Please see your tax advisor for
further details. TSACG understands that your personal information and privacy are important,
and we make every effort to ensure that the information you submit for a transaction is
recorded accurately, retained securely, and used only in accordance for the purpose intended.
Please note that relevant information about your transaction may be shared with, and
between, employers, 403(b)/457(b)/401(a) investment provider(s), and TSACG.
Copyright © 2018 TSA Consulting Group, Inc./TSACG ver.71618
Where and how should TSACG send the completed paperwork?
TSACG should mail or
fax (select one option only**) this form and all
other paperwork associated with this transaction to the following
Investment Provider or Agency:
(PLEASE TYPE OR PRINT LEGIBLY)
Investment Provider/Agency Name:
___________________________________________________________________________
Address:___________________________________________________________________
___________________________________________________________________________
City: _________________________________ State: ________ Zip: ____________
Fax Number: _______________________________________________________
**If you select more than one option, the default return method will be based on how
the information was originally submitted to TSACG. Please note, if the indicated
investment provider above accepts faxes the document(s) will be faxed rather than
mailed.
Fax This Form and All Accompanying Documents To:
Fax Numbers: 1-866-741-0645 or 1-866-814-0622
Carefully verify fax number dialed.
NOTE: Faxed transactions require 24 hours for verification of receipt by TSA.
E-mail confirmation of receipt will be sent as soon as verification is possible.
TSA Consulting Group, Inc. • Participant Services
P.O. Box 4037 • Fort Walton Beach, FL 32549-4037
Phone: 1-888-796-3786 Opt. 4 • Email: recordkeeping@tsacg.com
*Transaction status notification provided only if email address is provided and is legible.
Current Employer Employer/Plan Sponsor Name Termination Date (If applicable)
Former Employer
City, State, and Zip
Employee E-mail Address*
Employee Mailing Address Employee SSN Date of Birth
Employee/Participant Name (If different at time of employment please provide proof of legal name change) Employee Daytime Phone Number
Agent or Advisor Name Agent or Advisor Phone Agent or Advisor E-mail Address *
Transaction Submission Instructions
All transactions require the completed paperwork from the Investment Provider company. The Transaction Information (TI) form provides important
information regarding your request and is vital to ensuring proper processing.
Important: If your rollover or withdrawal request is due to the qualifying event of separation from service, your termination date must be verified by your employer.
Contract Exchanges
As of January 1, 2009, participants may only exchange their accounts among the authorized providers in the employer’s 403(b) Plan.
After verifying that the selected new provider is a current authorized provider, you must complete any forms required by the provider (usually supplied by the new investment provider), as well as
a TI form. All completed forms should be submitted to TSACG for processing.
1
ORP
Optional Retirement Plan: An optional defined contribution plan available to specific state employees in lieu of the standard state retirement plan.
Return Method
Participants should fax to TSACG all investment provider paperwork and the TSACG TI form. All paperwork, upon approval, will be mailed or faxed as directed on the TI.
Submitting Transaction Requests
All transaction requests should be faxed to TSACG for processing:
Fax: 1-866-741-0645 or 1-866-814-0622
Email: recordkeeping@tsacg.com
Mail: TSA Consulting Group, Inc., Attn: Participant Services, P.O. Box 4037, Fort Walton Beach, FL 32549-4037
Overnight Delivery: TSA Consulting Group, Inc., Attn: Participant Transactions, 73 Eglin Parkway NE, Suite 202,
Fort Walton Beach, FL 32548
TSACG wants to assist you in the most efficient manner possible. Carefully reviewing all documentation, verifying that you
have signed all necessary forms, and verifying that you have included any necessary evidence will help us to reach this
goal and avoid delays that are caused by incomplete documentation. Our customer service representatives are available to assist you at
1-888-796-3786, option 4 or recordkeeping@tsacg.com
.
Transaction Requested Forms needed for Processing
Cash Distribution/Withdrawal—Requires a
distributable event (i.e., age eligibility, separation
from service, or death)
1. Completed Investment Provider company paperwork.
2. Completed TI form, which includes completion of page 1 of this document.
403(b) Hardship Withdrawals
1.Completed Investment Provider company paperwork.
2.Completed 403(b) Hardship Withdrawal Disclosure form located online at
https://www.tsacg.com/individual/plan-transactions/
3. Evidence of expenses equal to or more than the amount requested.
4. Completed TI form, which includes completion of page 1 of this document.
Guidelines for a Hardship Withdrawal can be found online at
https://www.tsacg.com/individual/plan-transactions/
457(b) Unforeseen Emergency
Withdrawals
1.Completed Investment Provider company paperwork.
2.Completed 457(b) Unforeseen Emergency Withdrawal disclosure form located online at
https://www.tsacg.com/individual/plan-transactions/
3. Evidence of expenses equal to or more than the amount requested.
4. Completed TI form, which includes completion of page 1 of this document.
Rollovers (into and out of the Plan)
1. Completed Investment Provider company paperwork.
2. Completed TI form, which includes completion of of page 1 of this document.
403(b)Contract Exchanges/457(b) Transfer
1. Completed Investment Provider company paperwork.
2. Completed TI form, which includes completion of page 1 of this document.
Employer-to-Employer Transfers
1. Completed Investment Provider company paperwork.
2. Completed TI form, which includes completion of page 1 of this document.
Purchase of Service Credit Transfer
1. Completed Investment Provider company paperwork.
2. Completed State Retirement System paperwork.
3. Completed TI form, which includes completion of page 1 of this document.
Loans
1. Completed Investment Provider company paperwork.
2. Completed TI form, which includes completion of page 1 of this document.
Note: If requesting a residential loan, proof of home purchase must also be submitted.
Page 2 of 2
TSACG is not responsible for transaction requests submitted to a
misdialed fax number resulting in personal and private information being
sent to a wrong location. Please check the fax number carefully before
sending transactions to TSACG.
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Completed 28 December 2021

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