RI 38-117 Rollover Election

Form 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.
Please reply by

Taxable Portion

Non-taxable Portion

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

Claim Number

Your Social Security Number

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

Claim Number

Name of Deceased Employee or Annuitant

Your Social Security Number

Social Security Number of Deceased

Part 3 - Rollover Election (Select ONE option. If you select Option B, the organization(s) accepting your
rollover must complete Part 4.
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 into a traditional IRA or an eligible
employer plan.
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 __________________________________________________________________ with no Federal income
tax withheld from any taxable portion not rolled into a Roth IRA.
This rollover is to a Roth IRA.
Please withhold 20% Federal income tax.
Pay $__________ to __________________________________________________________________ with no Federal income
tax withheld from any taxable portion not rolled into a Roth IRA.
This rollover is to a Roth IRA.
Please withhold 20% Federal income tax.
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.
Send all the payments to me at the address shown below. I will deliver the payments to the institution(s) named.
Your Mailing Address (If you 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 should use.)

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 (If you elect Option B, Part 4 must be completed.)

Previous editions are not usable.

Date (mm/dd/yyyy)

Daytime telephone number with area code

Email address

RI 38-117
Revised March 2011

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 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 name of certifying representative

Telephone number with area code

Signature of certifying representative

Date of certification (mm/dd/yyyy)

Name 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 name of certifying representative

Telephone number with area code

Signature of certifying representative

Date of certification (mm/dd/yyyy)

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, at 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.
Added Privacy Act and Public Burden Statements

Reverse of RI 38-117
Revised March 2011