RI 38-117, Rollover Election

Form Approved:
OMB No. 3206-0212

United States
Office of Personnel Management
Retirement Operations Center
P.O. Box 45
Boyers, PA 16017-0045

Rollover Information

Claim number
Case name

l

This notice dated
Please reply by

This letter explains an important election available to you that will affect your lump-sum payment. You have until the “reply by”
date shown above to decide how you want your benefit to be paid. The enclosed “Special Tax Notice Regarding Rollovers”
explains how the election affects your payment. Please read carefully all of the information provided with this letter
before making your decision.
Rollover Allowed
Effective January 1, 2002, you are permitted to roll over certain benefits paid after December 31, 2001, into an individual
retirement arrangement (IRA), the Thrift Savings Plan, or an eligible employer plan under certain conditions. If the U.S. Office of
Personnel Management (OPM) pays the taxable portion of your payment as a direct rollover, no tax is withheld. If OPM pays the
taxable portion to you, 20% Federal income tax must be withheld, but to defer income tax you have the option to roll over part
or all of the taxable portion yourself within 60 days after you receive the payment. You may then apply for a refund of the 20%
withheld when you file your tax return. You may roll over any non-taxable portion of your payment, as well as any taxable portion,
subject to the following conditions.
v You can roll over the taxable portion to an IRA, a eligible employer plan, or your own open account with the Thrift Savings
Plan.
v You can roll over the non-taxable portion to an IRA, but you must keep track of the taxable and non-taxable amounts in the
IRA. You can also roll over the non-taxable portion to an eligible employer plan, if the plan certifies that it is willing to accept
the payment in a direct trustee-to-trustee transfer from OPM, and to account for the payment in accordance with tax law. The
plan makes this certification on the enclosed Rollover Election Form, RI 38-117. You cannot roll over the non-taxable portion
to the Thrift Savings Plan.
v Your taxable portion and your non-taxable portion are shown below under “Description of Payment.”

Description of Payment
You are due a lump-sum payment for _____________________________________ .
The amount of your payment is __________________________________________ .
The taxable portion is __________________________________________________ .
The non-taxable portion is ______________________________________________ .

Previous edition is not usable.

(Continued on reverse side)

RI 38-118
Revised July 2002

Election Options
The enclosed “Rollover Election” form provides two options for receiving your benefit. Please select one option and return your
completed election in the enclosed pre-addressed envelope to reach the Office of Personnel Management (OPM) by the date
shown at the top of this letter.
If you choose Option A, we will make the distribution payable to you, less 20% tax withholding on the taxable portion, and send it
to your regular payment address. To defer income tax you have the option to roll over part or all of the taxable portion yourself
within 60 days after you receive the payment. You may include part or all of the non-taxable portion with the rollover of the taxable portion.
If you choose Option B, we will make all or part of the distribution payable to the Individual Retirement Arrangement [(IRA(s]) or
eligible employer plan you specify, with no tax withheld, and send it to you or to the account you specify. We will pay to no more
than two IRAs or plans including the Thrift Savings Plan. We will make any remainder of the benefit payable to you, less 20% tax
withholding on any remaining taxable portion, and send it to your regular payment address. To defer income tax you have the
option to roll over part or all of the remaining taxable portion yourself within 60 days after you receive the payment. If you choose
Option B, the amount you elect to roll over must be $500.00 or more. You may include part or all of the non-taxable portion with
the rollover of the taxable portion.
Please note that if you elect Option B, Part 4 must be completed by the financial institution administering your
individual retirement arrangement (IRA) or by your eligible employer plan before we can process your election.
Tax Information
See the enclosed “Special Tax Notice Regarding Rollovers.” Consult a qualified tax advisor or the Internal Revenue
Service if you need more information on tax matters.
Questions
If you have questions about the rollover election, you may send us email at [email protected] or call the OPM Retirement Information Office, 1-888-767-6738, Monday through Friday, 7:30 a.m. to 7:45 p.m., Eastern time. Customers within local calling distance
to Washington, D.C., must contact us on (202) 606-0500. Address written inquiries to:
U.S. Office of Personnel Management
Retirement Operations Center
P.O. Box 45
ATTN: ROLLOVERS
Boyers, PA 16017-0045
Please furnish the claim number shown on the other side of this notice when contacting OPM and give us your daytime telephone
number.
Important
If you do nothing, we will make payment to you after the “reply by” date shown on the front of this page, less 20% tax on the taxable portion, and send it to your regular payment address. You have the option to rollover part or all of the taxable portion yourself
tax free within 60 days after you receive the payment.
Enclosures: Special Tax Notice Regarding Rollovers, RI 37-22
Rollover Election, RI 38-117
Return Envelope
Privacy Act Statement
Public Law 102-318, authorizes the solicitation of this information. The data you furnish will be used to identify direct rollovers and
determine Federal income tax withholding on your lump-sum benefit. The information may be shared and is subject to verification via
paper, electronic media, or through the use of computer matching programs, with national, state, local or other charitable or social security administrative agencies in order to determine benefits under their programs, to obtain information necessary for determination or
continuation of benefits under this program, or to report income for tax purposes. It may also be shared and verified, as noted above,
with law enforcement agencies when they are investigating a violation or potential violation of civil or criminal law. Section 7701 of title
31, U.S. Code requires that any person doing business with the Federal Government furnish a Social Security Number or tax identification number. The Government may use your number in collecting and reporting amounts that you owe the Government. Failure to furnish information may result in Federal income tax withholding from your lump-sum benefit.

Public Burden Statement
We think providing this information takes an average 30 minutes per response, including the time for reviewing instructions, getting the
needed data, and reviewing the requested information. Send comments regarding our estimate or any other aspect of this form, including suggestions for reducing completion time, to the U.S. Office of Personnel Management, OPM Forms Officer, (3206-0212), Washington, D.C. 20415-7900. The OMB number, 3206-0212, is currently valid. OPM may not collect this information, and you are not
required to respond, unless this number is displayed.
Reverse of RI 38-118
Revised July 2002