RI38-117_November2008 Markup

Fonn Approved:
OMB 3206-0212

Rollover Election Form
Use this form to elect how you want your lump sum paid. Please carefully read all of the information provided with this form before
you make your election. A mistake in completing this form could prevent the Office of Personnel Management (OPM) from paying
as you wish or could cause delay in processing your payment. If we do not receive your election by the reply date shown, we will
pay you as though you had selected Option A.
Taxable Portion

Please reply by

Non-taxable Portion

I

I

Part 1 - For use by Former Employees and Retired Employees (Complete Part 1 and Part 3.)
Your Naine

Claiin Nuinber

Your Social Secuiity Nuinber

I

I

Part 2 - For use by Surviving Spouses, Former Spouses, and Designated Beneficiaries (Complete Part 2 and Part 3.)
Your Naine

Claiin Number

Your Social Secuiity Nuinber

I

Name of Deceased Employee or Alumitant

Social Security Number of Deceased

Part 3 - Rollover Election (Select ONE option. Ifyou select Option B, the organization(s) accepting your
rollover must complete Part 4.
I

Option A: Pay All to Me
Make the entire lump sum payable to me and send it to the mailing address shown below. I understand that the Office of Personnel
Management is required to withhold 20% of any taxable portion for Federal income tax and that to defer income tax I have the
option to roll over part or all of any taxable portion within 60 days after receipt.

Option B: Pay As Shown Below. If you roll over less than 100% of this distribution, the total amount that you roll over to each
organization must be at least $500. If you elect to roll any part of this distribution into your Thrift Savings account, you must comply
with the special instructions on the back of the form.
pay$
to
income tax withheld from any taxable portion. Sentence added

with no Federal

pay$
to
income tax withheld from any taxable portion. Sentence added

with no Federal

Pay any remainder to me, less 20% Federal income tax withholding from any taxable portion you pay to me.
And check one box below.
Send the payments directly to the institution(s) named. Send any remainder to me at the address shown below.

n Send all the payments to me at the address shown below. I will deliver the payments to the institution(s) named.
Your Mailing Address (Ifyou are enrolled in the Direct Deposit Program, this lump sum will be deposited in your account and we do not need your
mailing address in this block unless it is a new address we s h o ~ ~use.)
ld

My signature below certifies that I have made the election shown above and that I understand that distributions from the plan to which
the rollover is made may be subject to different restrictions and tax consequences than those that apply to distributions from OPM. I
also understand that if I roll over non-taxable funds into an IRA, I am responsible to account separately for the taxable and non-taxable
portions of the amount rolled over.
Signature @you eke! Option B, Part 4 nrlrst be conrpleterl.)

Date (mm/dd/yyyy)

Daytime Telephone Number with area code

field was added for email address.

Previous editioos are not usable

R138-117
Revised November 2008

Part 4 - Certification from Financial Institutions or Eligible Employer Plans
Name of institution or eligible employer plan

Address of institution or plan

Account number of IRA or eligible einployer plan

Certification: As a representative of the fmancial institution or eligible employer plan named above, I confirm the account number for
the individual named above and the address. I certify that the financial institution or plan named above agrees to accept funds as a direct
trustee-to-trustee transfer from the Office of Personnel Management, to deposit them in an eligible IRA or eligible employer plan as
defined in the Internal Revenue Code, and to account for these monies in compliance with the Internal Revenue Code.
Typed or printed name of certifying representative

Telephone number with area code

Signature of certifying representative

Date of ceitification (mm/ddbyyy)

Naine of institution or eligible employer plan

Address of institution or plan

...............................................

Account number of IRA or eligible employer plan

Certification: As a representative of the financial institution or eligible employer plan named above, I confirm the account number for
the individual named above and the address. I certify that the financial institution or plan named above agrees to accept funds as a direct
trustee-to-trustee transfer from the Office of Personnel Management, to deposit them in an eligible IRA or eligible employer plan as
defined in the Internal Revenue Code, and to account for these monies in compliance with the Internal Revenue Code.
Typed or printed na~neof certifying representative

Telephone number with area code

Signature of certifying representative

Date of ceititication (mm/ddbyyy)

Instructions for Rollover to the Federal Retirement Thrift Savings Plan
The Thrift Savings Plan (TSP) will not accept non-taxable (post-tax) monies. You must have an open TSP account. Before the
Office of Personnel Management (OPM) can complete a rollover to your Thrift Savings account, you must sign and submit Form
TSP-60, Request for a Transfer Into the TSP, to OPM. Submit both the TSP-60 and this form, RI 38-117, a1 the same time. OPM
will complete its portion of the form and fax it to the Thrift Savings office for processing. The form must be approved by the Thrift
Savings Board and the Board must notify OPM to transfer the funds. This process can take two to three weeks. Form TSP-60 is
available on the internet at http://www.tsp.gov/forms.

Reverse of RI 38-1 17
Revised November 2008