The University of Texas System
VESTING/TERMINATION STATUS FORM
Name: ____________________________________________________ Social Security Number: _____________________ __________
The University of Texas ___________________________________________________________________________________________
□ Employee terminated from employment effective ________________ and was participating in (check any that
apply):
□ Optional Retirement Program (ORP)
□ UTSaver 403(b) Tax Sheltered Annuity (TSA)
□ UTSaver 457(b) Deferred Compensation Plan (DCP)
For ORP Purposes Only
□ Employee is employed and has met the Optional Retirement Program (ORP) vesting requirement.
o Final ORP deposit (or adjustment) in the amount of $_________ is included on our report for
_____________________ which will be/was sent to you on ___________________. Final disposition of
Employee’s account must not be made until this deposit (or adjustment) has been received.
o Has employee vested? Yes____ No____
□ ORP Employer contributions should be refunded Yes____ No____
o Amount to be refunded $________
[Pursuant to 19 Texas Administrative Code Sections 25.6(a)(11) and 25.6(f)(2), you are hereby requested to return
all Employee forfeited ORP Employer contributions within 30 days of receiving this request.]
All ORP Employer contributions should be mailed to:
______________________________________________________________________
______________________________________________________________________
_______________________________________________________________________
Comments: _______________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Name (Print):
______________________________________________ _________________ _____________________________________
Authorized Signature Date
Notice about Social Security Numbers
Federal law requires The University of Texas System to report income and SSN’s for all employees to whom compensation is paid. Employee
SSNs are maintained and used by The University of Texas System for payroll and benefits purposes and are reported to Federal and State
agencies on forms required by law for benefits purposes. Further disclosure of the employee’s social security number will be governed by
the Public Information Act (Chapter 552 of the Texas Government Code).
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