RI 94-007_2011_05_MarkUp

Form approved:
OMB No. 3206-0218

U.S. Office of Personnel Management
Retirement Operations
Washington, D.C. 20415-3520

Death Benefit Payment Rollover Election
Please read all of the information we have provided with this election form before you make your election.
Survivor's Name (last, first, middle)

CSF Number

Date (mm/dd/yyyy)

Please Reply By

You are eligible to roll over the following survivor benefit(s)

Type of
Benefit
Amount

Basic Employee Death Benefit
(BEDB)*

Monthly $
or
Lump sum $

Employee contributions,
Excess contributions,
Voluntary contributions, plus interest

Lump sum $

Alternative Annuity

Lump sum $

Total amount that can be rolled over (The total of the benefits identified above.)

Lump sum $
Taxable Portion $
Non-Taxable Portion $

or

Monthly Basic Employee Death Benefit $
Taxable portion $
NONE
Non-Taxable portion $
Plus
Lump Sum $
Taxable portion $
Non-Taxable portion $

Mail the completed election form to the address checked below:
U.S. Office of Personnel Management
Retirement Operations
Claims 1
Attn: ____________________, Room _______________
1900 E Street, N.W.
Washington, D.C. 20415-3520

U.S. Office of Personnel Management
Retirement Operations Center
Attn: ____________________________
P.O. Box 45
Boyers, PA 16017-0045

*If you are eligible to receive a basic employee death benefit, you can elect either a lump sum payment or 36 monthly installments of the benefit
on this form, even if you have elected a different method of payment on another form. Complete the appropriate box on the Death Benefit
Payment Rollover Election Form to verify how you would like to have your basic employee death benefit paid to you.
Privacy Act Statement
Solicitation of this information is authorized by the Unemployment Compensation Amendments of 1992 (Public Law 102-318). The information you furnish will
be used to properly tax your benefits. 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. Failure to
provide information may delay or prevent action on your application.

Public Burden Statement
We estimate this form takes an average of one hour per response to complete, 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 Office of Personnel Management (OPM), Retirement Services Publications Team (3206-0218), Washington, D.C. 20415-3430. The OMB number,
3206-0218, is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.
Previous edition is not usable.

RI 94-7
Revised May 2011

Survivor's Name (last, first, middle)

CSF Number

Death Benefit Payment Rollover Election Form
Make an election in Section 1 or Section 2 below and complete the Certification of Your Selections section below. If you make
an election in Section 2, the election form must also be completed by a representative of your financial institution or eligible
employer plan.

Section 1
Pay any benefits eligible for a rollover directly to me.
I do not want to roll over any part of my eligible benefits into an Individual Retirement Arrangement (IRA) or eligible employer plan. I
understand that 20% of the taxable amount of the payment(s) will be withheld for tax, but that I can roll over part or all of the taxable
amount to a qualified account within 60 days to defer income tax.
If applicable: I have elected to receive my BEDB (check one)

as a Lump Sum.

in monthly installments.

Section 2
I want to roll over all or part of my eligible benefits into an Individual Retirement Arrangement (IRA), eligible employer plan or Thrift Savings
Plan account. Complete Parts A and B below and have your financial institution(s) or plan(s) complete the Certification by Financial
Institution or Eligible Employer Plan section on the reverse of this page. If you are rolling over your death benefits into your Thrift Savings
Plan (TSP) account, the TSP does not need to complete the Certification by Financial Institution or Eligible Employer Plan.

Part A
Roll the following amount(s) over into the IRA(s), Eligible Employer Plan(s) or Thrift Savings Plan account specified below:
(Please state ALL or the specific amount in each category below. If you roll over less than 100% of your total payment to a financial institution,
the total payment to each IRA or plan must be at least $500.)
Roll the following amount over to _______________________________________________________________________________________.
(Name of IRA/Plan)
Withhold 20% Federal income tax from amount rolled over to Roth IRA
Is this a Roth IRA?
yes
no
Lump Sum: $__________ of the taxable amount

BEDB Monthly Installment: $__________ of the taxable amount

$__________ of the non-taxable amount
(All of the BEDB amount is taxable.)
Roll the following amount over to_______________________________________________________________________________________.
(Name of IRA/Plan)
Is this a Roth IRA?
yes
no
Withhold 20% Federal income tax from amount rolled over to Roth IRA
Lump Sum: $__________ of the taxable amount

BEDB Monthly Installment: $__________ of the taxable amount

$__________ of the non-taxable amount

(All of the BEDB amount is taxable.)

If I elect to roll over less than all, I understand that the taxable portion of any balance made payable to me will be subject to 20% tax withholding
and that I can roll any part of it over to a qualified account within 60 days to defer income tax.
If applicable: I have elected to receive my BEDB (check one)

as a Lump Sum.

in monthly installments.

(The BEDB election you make on this form is the election the Office of Personnel Management (OPM) will honor even if you elected a different
method of payment at some other time. Information concerning the lump sum and installment payments is available on the first page of this
form.)

Part B
I want to have the rollover amount sent: (check one box below)
Directly to my financial institution or eligible employer plan.

To me for delivery to the financial institution or eligible employer plan. In
this case, the check will be made payable to the IRA Account or plan.

The Certification by Financial Institution or Eligible Employer Plan section, found on the reverse of this page must also be completed.

Certification of Your Selections
My signature below certifies that I have made the election shown above and have read and understand the information on this form and in the enclosures included
with it. I also 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. In addition, I understand that if I roll over non-taxable funds into an IRA, I am responsible for accounting separately for the
taxable and non-taxable portions of the amount rolled over.
Daytime telephone number (including area code)
Date (mm/dd/yyyy)
Signature

Email Address

RI 94-7
Page 2
Revised May 2011

Certification by Financial Institution or Eligible Employer Plan
This part must be completed by your financial institution or eligible employer plan
if all or part of your benefit is made payable to an IRA or eligible employer plan.
Name and address of financial institution or eligible employer plan

Account number

Certification: As a representative of the financial institution or plan named above, I confirm the account number for the individual named
on page 2 of this form and the address of this financial institution or plan. 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.
Signature of certifying representative

Telephone number (including area code)

Typed or printed name of certifying representative

Date (mm/dd/yyyy)

Certification by Financial Institution or Eligible Employer Plan
This part must be completed by your financial institution or eligible employer plan
if all or part of your benefit is made payable to an IRA or eligible employer plan.
Name and address of financial institution or eligible employer plan

Account number

Certification: As a representative of the financial institution or plan named above, I confirm the account number for the individual named
on page 2 of this form and the address of this financial institution or plan. 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.
Signature of certifying representative

Telephone number (including area code)

Typed or printed name of certifying representative

Date (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 TSP 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 94-7, at the same time. OPM will complete its portion of the form and fax it to
the TSP 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 www.tsp.gov.

RI 94-7
Reverse of Page 2
Revised May 2011