Direct Rollover/
Trustee-to-Trustee Transfer
of Funds for the Purchase
of Additional Service Credit
Pensions & Benefits
Public Employees’ Retirement System (PERS)
Teachers’ Pension and Annuity Fund (TPAF)
Police and Firemen’s Retirement System (PFRS)
State Police Retirement System (SPRS)
Judicial Retirement System (JRS)
TABLE OF CONTENTS
General Information ............................................................................................ 1
Eligible Plans ...................................................................................................... 1
Instructions for Completing the Rollover/Transfer Request form ........................ 2
If you are using tax-deferred contributions
from the New Jersey State Employees Deferred Compensation Plan ......... 2
If you are using tax-deferred contributions
from a 401(A), 401(K), 403(A), 403(B), Or 457(B) Plan ............................... 2
If you are using tax-deferred contributions
from an Individual Retirement Account (IRA) ............................................... 3
For More Information .......................................................................................... 4
Rollover/Transfer Request form
Purchase of Service Credits Transfer Request
Who Should Complete this Application?
This application is for use by members who are purchasing additional
pension service credit and who wish to pay for this additional service
by rolling over funds from another qualied retirement savings plan.
Do not complete this rollover request unless you have already re-
ceived a Purchase Cost Quotation Letter from the New Jersey Division
of Pensions & Benets (NJDPB) that indicates the type, amount, and
cost of any service you are eligible to purchase.
To obtain a Purchase Cost Quotation Letter you must rst le an Ap-
plication to Purchase Service Credit via the Member Benets Online
System (MBOS).
Page 1
GENERAL INFORMATION
Please read this booklet carefully before completing the Rollover/Transfer Request form.
This booklet contains:
— information on the types of funds that can be rolled over;
— instructions on how to complete the Rollover/Transfer Request form for the various types of
qualied plans;
— the Rollover/Transfer Request form; and
— a Purchase of Service Credits Transfer Request (for those using tax-deferred contributions from
the New Jersey State Employees Deferred Compensation Plan only).
If you have a Purchase Cost Quotation Letter and wish to pay for your service credit by rolling over
funds from another retirement plan, continue reading to determine if your plan is eligible for rollover
and how to complete the application.
ELIGIBLE PLANS
Only certain types of distributions are eligible for transfer/rollover treatment and it is your responsibility
to ensure such eligibility.
The types of plans eligible for direct rollover or trustee-to-trustee transfer are:
— 401(a) - Qualied plan (including 401(k) plan) and 403(a) qualied annuity
— 403(b) - Tax-Sheltered Annuity Plan
— 457(b) - State and Local Government Deferred Compensation Plan
— IRA - With tax-deferred funds
- Traditional IRA
- SIMPLE IRA (must be over 2 years old)
- Simplied Employee Pension Plan (SEP)
- Conduit IRA
- Rollover IRA
Note: The NJDPB cannot accept rollovers from a Roth IRA or a Coverdell Education Savings
Account (formerly known as an education IRA).
If you are unsure if your plan is an eligible plan, see your nancial institution or disbursing
plan’s administrator.
Page 2
INSTRUCTIONS FOR COMPLETING
THE DIRECT ROLLOVER/TRUSTEE-TO-TRUSTEE
TRANSFER OF FUNDS FORM
The procedures for a direct rollover or trustee-to-trustee transfer vary depending on the type of plan from which the
funds are being transferred and are listed separately by type. After you have received your Purchase Cost Quotation
Letter, follow the instructions described below that apply to the type of transaction you are requesting.
If You Are Using Tax-Deferred Contributions from
the New Jersey State Employees Deferred Compensation Plan
The New Jersey State Employees Deferred Compensation Plan (NJSEDCP) is an eligible 457(b) Plan. If you are a
member of the NJSEDCP, you may use your tax-deferred contributions for the full or partial payment of a purchase.
You should verify the balance of the funds you have available for use as a direct transfer prior to completing the Roll-
over/Transfer Request form by contacting Empower at 866-657-3327.
After you have received a valid Purchase Cost Quotation Letter, complete Sections A, B, and D of the Rollover/
Transfer Request form. This will authorize the transfer of your funds from the NJSEDCP to pay for either a portion or
the entire cost of your purchase. You must also complete sections A-E of the Purchase of Service Credits Transfer
Request included at the end of this packet.
You should select “Direct Transfer from the NJSEDCP” in Section B of the Rollover/Transfer Request form and submit
the completed form and the completed Purchase of Service Credits Transfer Request – and if applicable a check for
any personal funds you are using to pay for the purchase – to the attention of the Cash Receipts Section, Division
of Pensions & Benets, P.O. Box 295, Trenton, NJ 08625-0295.
If the amount you indicate in Section B on the Rollover/Transfer Request form – along with any check if you also sub-
mit personal funds – does not satisfy the entire cost of the purchase, the remaining balance due on the purchase will
be scheduled as payroll deductions with interest.
To ensure proper handling of your purchase, please make sure the Rollover/Transfer Request form, the Purchase of
Service Credits Transfer Request, and any checks are attached together.
If you have applied for multiple periods of service credit and received more than one Purchase Cost Quotation Letter,
include a copy of the quotation letter(s) for the purchase that you wish to authorize along with your completed Rollover/
Transfer Request and the Purchase of Service Credits Transfer Request forms. This will ensure that the funds are
credited to the correct period of service.
Note: A member is unable to specify the NJSEDCP investment fund from which the monies will be transferred for the
payment of the purchase. The transfer of funds from the NJSEDCP is based on the relative value of each investment
alternative to the total value of your account. For example, if your investments are distributed equally between two of
the investment funds, and you specify $2,000 to be transferred for the cost of the purchase, then $1,000 will be trans-
ferred from each of the two investment funds.
If You Are Using Tax-Deferred Contributions from
a 401(A), 401(K), 403(A), 403(B), Or 457(B) Plan
Funds to be rolled over or transferred must be tax-deferred and from one of the following types of qualied or eligible
plans:
— 401(a) - Qualied plan (including 401(k) plan) and 403(a) qualied annuity
— 403(b) - Tax Sheltered Annuity Plan
— 457(b) - State and Local Government Deferred Compensation Plan
Note: No check will be accepted for a direct rollover or trustee-to-trustee transfer unless the completed Roll-
over/Transfer Request form accompanies the check. For this reason, it is critical that you coordinate the informa-
tion required to complete the rollover with the disbursing plan or nancial institution that will be issuing the check (any
rollover/transfer check submitted directly to this oce from the disbursing plan or nancial institution will be returned).
Page 3
After you have received a valid Purchase Cost Quotation Letter, complete Sections A, B, and D of the Rollover/Trans-
fer Request form. This will authorize the transfer of your funds from your disbursing plan or nancial institution to pay
for a portion or the entire cost of your purchase. When rolling over or transferring funds from a tax-deferred plan, you
should select — depending on the type of plan — either “Direct Rollover from a 401(a), 401(k), or 403(a) Plan” or
“Direct Rollover/Transfer from a 403(b) Annuity or 457 Plan (other than the NJSEDCP)” in Section B of the Rollover/
Transfer Request form.
Forward the Rollover/Transfer Request form to your disbursing plan or nancial institution for the completion of Sec-
tion C. The disbursing plan or nancial institution must return the completed Rollover/Transfer Request form
and distribution check directly to you.
The direct rollover/transfer check should be made payable to:
Name of Retirement System*
FBO** Participant’s Name
* From Section A of Rollover/Transfer Request form.
** “For the benet of”
Note: The participant’s Social Security number must be on all checks.
You should submit the completed Rollover/Transfer Request form you receive from your disbursing plan or nancial
institution, the distribution check — and, if applicable, a check for any personal funds you are using to pay for the pur-
chase — to the attention of the Cash Receipts Section, Division of Pensions & Benets, P.O. Box 295, Trenton,
NJ 08625-0295.
If the checks you submit do not satisfy the entire cost of the purchase, the remaining balance due on the purchase will
be scheduled as payroll deductions with interest.
To ensure proper handling of your purchase, please make sure the Rollover/Transfer Request form and any checks
are attached together.
If you have applied for multiple periods of service credit and received more than one Purchase Cost Quotation Letter,
include a copy of the quotation letter(s) for the purchase that you wish to authorize along with your Rollover/Transfer
Request form. This will ensure that the funds are credited to the correct period of service.
If You Are Using Tax-Deferred Contributions
from an Individual Retirement Account (IRA)
Funds to be rolled over from an IRA must be tax-deferred and from one of the following types of IRAs:
— Traditional IRA
— SIMPLE IRA (must be over 2 years old)
— Conduit IRA
— Rollover IRA
The NJDPB cannot accept rollovers from a Roth IRA or a Coverdell Education Savings Account (formerly known as
an education IRA).
Note: No check will be accepted for a direct rollover unless the completed Rollover/Transfer Request form
accompanies the check. For this reason, it is critical that you coordinate the information required to complete the
rollover with the disbursing plan or nancial institution that will be issuing the check (any rollover check submitted
directly to this oce from the disbursing plan or nancial institution will be returned).
After you have received a valid Purchase Cost Quotation Letter, complete Sections A, B, and D on the Rollover/
Transfer Request form. This will authorize the rollover of your funds from your disbursing plan or nancial institution to
pay for a portion or the entire cost of your purchase. When rolling over funds from an IRA, you should select “Direct
Rollover from an IRA” in Section B on the Rollover/Transfer Request form.
Forward the Rollover/Transfer Request form to your disbursing plan or nancial institution for the completion of Sec-
tion C. The disbursing plan or nancial institution must return the completed Rollover/Transfer Request form
and distribution check directly to you.
Page 4
The direct rollover check should be made payable to:
Name of Retirement System*
FBO** Participant’s Name
* From Section A of Rollover/Transfer Request form.
** “For the benet of”
Note: The participant’s Social Security number must be on all checks.
You should submit the completed Rollover/Transfer Request form you received from your disbursing plan or nancial
institution, the distribution check — and, if applicable, a check for any personal funds you are using to pay for the pur-
chase — to the attention of the Cash Receipts Section, Division of Pensions & Benets, P.O. Box 295, Trenton,
NJ 08625-0295.
If the checks you submit do not satisfy the entire cost of the purchase, the remaining balance due on the purchase will
be scheduled as payroll deductions with interest.
To ensure proper handling of your purchase, please make sure the Rollover/Transfer Request form and any checks
are attached together.
If you have applied for multiple periods of service credit and received more than one Purchase Cost Quotation Letter,
include a copy of the quotation letter(s) for the purchase that you wish to authorize along with your Rollover/Transfer
Request form. This will ensure that the funds are credited to the correct period of service.
FOR MORE INFORMATION
Information regarding the purchase of service credit is available on our website at www.nj.gov/treasury/pensions
If you have further questions about the purchase of service credit or the direct rollover/trustee-to trustee transfer of
funds after reading this booklet and visiting our website, you can contact the NJDPB Oce of Client Services at (609)
292-7524, by email at: [email protected], or by sending correspondence to the Division of Pensions &
Benets, P.O. Box 295, Trenton, NJ 08625-0295.
SECTION A — PARTICIPANT INFORMATION
SECTION B — DIRECT ROLLOVER/TRANSFER OPTIONS
SECTION C — DISBURSING PLAN CERTIFICATION (to be completed by plan administrator)
SECTION D — PARTICIPANT CERTIFICATION AND AUTHORIZATION
Name ______________________________________________________________________________________________________
First Middle Initial Last
Address ____________________________________________________________________________________________________
Street City State Zip Code
Social Security Number _______________________________ Phone Number __________________________________________
Indicate Retirement System (check one) oPublic Employees’ Retirement System
oTeachers’ Pension and Annuity Fund oState Police Retirement System
oPolice and Firemen's Retirement System oJudicial Retirement System
Type of Distribution (check one)
oDirect Transfer from the New Jersey State Employees Deferred Compensation Plan (NJSEDCP)*
oDirect Rollover from a 401(a), 401(k), or 403(a) Plan oDirect Rollover from an IRA
oDirect Rollover/Transfer from a 403(b) Annuity or 457 Plan (other than the NJSEDCP)
Type of Transaction Requested (check one)
oI am using rollover/transfer funds only: My disbursing plan will issue a check for the amount of $ ___________ for this purchase.
oI wish to use rollover/transfer funds along with personal funds: My disbursing plan will issue a check for the amount of
$ _________________ for the partial payment of this purchase and I am including a check in the amount of $ ________________
for the balance.
Note: If the checks you submit do not satisfy the entire cost of the purchase, the remaining balance due on the purchase will automatically be
scheduled as payroll deductions with interest.
Name of Disbursing Plan or Financial Institution _____________________________________________________________________
Type of Plan (Internal Revenue Code Section) ______________________________________________________________________
Plan Mailing Address __________________________________________________________________________________________
Street City State Zip
I certify that the funds are being or have been distributed from an eligible retirement plan as dened in IRC Section 402(C)(8)(B).
Specify Dollar Amount $ ____________ Authorized Plan Administrator Signature _________________________________________
I certify that the funds meet the requirements for a rollover or transfer. I assume responsibility for any tax consequences that may result if these require-
ments are not met. I certify that the information provided on this form and on any attached forms is true, correct, and complete to the best of my knowledge.
I authorize my disbursing plan to send me a check (except in the case of a direct transfer from the NJSEDCP) completed as indicated in the instructions
for this form for the amount indicated in Section B of this form.
Signature of Participant _______________________________________________________________ Date ______/______/______
Pension Member Number
___________________
State of New Jersey • Department of the Treasury
DIVISION OF PENSIONS & BENEFITS — CASH RECEIPTS SECTION
P.O. Box 295, Trenton, NJ 08625-0295
ROLLOVER/TRANSFER REQUEST FOR
THE PURCHASE OF SERVICE CREDIT
EP-0646-0824
Please read the instructions for completing this form carefully. You must return this
form along with all checks to the Division of Pensions & Benets at the address above.
*The Purchase of Service Credits Transfer Request must accompany this form. Please refer to the “If You Are Using Tax-Deferred
Contributions from the New Jersey State Employees Deferred Compensation Plan” section of the “Instructions” page.
524954-01
Last Name First Name M.I. Social Security Number Number
STD FPRCRD ][05/13/24)( 524954-01 WITHDRAWAL
NO_GRPG 52478/][GU37)(/][DIXK
DOC ID: 25212233)(
Page 2 of 4
D
How do I want my transfer delivered? (Continue to the next section after completing.)
Select One - Delivery of payment is based on completion of the withdrawal process, which includes
receipt of a complete request in good order and additional/required information from my employer.
Check by USPS Regular Mail
●
Estimated delivery time is 7-10 business days
●
No additional charge
Check by Express Delivery
●
Estimated delivery time is 1-2 business days
●
A non-refundable charge of up to $25.00 will be deducted, in addition to any withdrawal fees, for each transaction, which will be added to
the purchase of service credit transfer amount requested.
●
Available for delivery, Monday - Friday, with no signature required upon delivery
●
If address is a P.O. Box, check will be sent by USPS Priority Mail and estimated delivery time is 2-3 business days.
E
Signatures and Consent (Signatures must be on the lines provided.) (After receiving ALL required signatures, continue to the next section.)
My Consent (Please sign on the ‘My Signature’ line below.)
I acknowledge that I have read, understand and agree to all pages of this Purchase of Service Credits Transfer Request and the Purchase of
Service Credits Transfer Guide and affirm that all information that I have provided is true and correct. Pursuant to the enclosed Notification of
Eligibility/Acceptance letter from my employer’s governmental defined benefit plan, I hereby authorize the transfer of deferred (pre-tax) funds in the
amount indicated above from my Governmental 457(b) Plan for the purpose of purchasing retirement service credits. I understand the following:
●
Funds may impose redemption fees on certain transfers, redemptions or exchanges if assets are held less than the period stated in the fund's
prospectus or other disclosure documents. I will refer to the fund's prospectus and/or disclosure documents for more information.
●
Under penalty of perjury, I certify that the U.S. Social Security number or U.S. Taxpayer Identification number I have provided in Section A is
correct. I am a U.S. person if I marked the U.S. Citizen or U.S. Resident Alien box in Section A of this form.
●
Additional authentication may be necessary before my withdrawal is processed and/or payment released.
●
My withdrawal may be subject to fees and/or loss of interest based upon my investment options, my length of time in the Plan and
other possible considerations. If I have not been advised of the fees and risks associated with my withdrawal, I may contact Service
Provider for a withdrawal quote at 1-866-657-3327.
Any person who presents a false or fraudulent claim is subject to criminal and civil penalties.
My Signature Date (Required)
A handwritten signature is required on this form. An electronic signature will not be accepted and will result in a significant delay.
My Authorized Plan Administrator Signature (Please sign on the 'Authorized Plan Administrator Signature' line below.)
I certify that this request is in compliance with applicable Plan provisions and federal law and that the participant has received from the Plan any
notices required by law. I approve this transfer as it is presented on this form.
I represent that I am an authorized signer on behalf of the above-named Plan and have an authority to instruct Service Provider to process this form.
Authorized
Plan Administrator Signature Date (Required)
A handwritten signature is required on this form. An electronic signature will not be accepted and will result in a significant delay.
Print Full Name
F
Where should I send this form?
After all signatures have been obtained, this form and a copy of the Notification of Eligibility/Acceptance letter can be
Uploaded Electronically:
Login to account at
empower.com/njplans
Click on Upload Documents to submit
OR Sent Regular Mail to:
Empower
PO Box 56025
Boston, MA 02205-6025
OR Sent Express Mail to:
Empower
8515 E. Orchard Road
Greenwood Village, CO 80111
We will not accept hand delivered forms at Express Mail addresses.
The group variable annuity insurance products are issued through Empower Annuity Insurance Company, Hartford, CT and distributed through Empower
Financial Services, Inc., (EFSI). Both are Empower companies and each organization is solely responsible for its financial condition and contractual
obligations. Annuity contracts contain exclusions, limitations, reductions of benefits and terms for keeping them in force. The annuity or certain of its
investment options or features may not be available in all states. Policy forms currently available include DC- 08-TGWB-2011, ALC-408-TGWB-2011-NR,
ALC-408-TGWB-2011-ROTH, IND-IFX-TGWB-2013-NR, IND-IFX-TGWB-2013-ROTH or state variation thereof.
You could lose money by investing in money market investments. Although they seek to preserve the value of your investment at $1 or $10.00 per share
(see the prospectus), there is no guarantee they will. An investment in a money market investment is not insured or guaranteed by the Federal Deposit
Insurance Corporation or any other government agency. The money market investment’s sponsor has no legal obligation to provide financial support to
the portfolio, and you should not expect that the sponsor will provide financial support to the portfolio at any time. The yield quotation more closely reflects
the current earnings of the portfolio than the total return quotation.
DAES/MANUAL/SR 13644521
Page 1 of 5
Purchase of Service Credits Transfer Request
Governmental 457(b) Plan
STD FPRCRD ][05/13/24)( 524954-01 WITHDRAWAL
NO_GRPG 52478/][GU37)(/][DIXK
DOC ID: 25212233)(
Page 1 of 4
NEW JERSEY STATE EMPLOYEES DEFERRED COMPENSATION PLAN 524954-01
When would I use this form?
When I am requesting a transfer to purchase permissible service credits with my employer's governmental defined benefit plan.
●
Please note that this withdrawal request may be subject to an administrative review period prior to processing and the investments in your account
will not be sold until the withdrawal is processed. The administrative review period may take several business days. Note that your investments may
fluctuate with market performance so you may want to redirect or diversify those investments prior to making a withdrawal request. If you initiate a
fund transfer during the administrative review period, it may delay the processing of your withdrawal. If you want to make changes to the investments
in your account prior to withdrawal, please contact Service Provider or access your account online.
Additional Information
●
Return Instructions for this form are in Section F.
●
By logging into my account on the website at empower.com/njplans, I may track the status of this request.
●
For questions regarding this form, refer to the attached Purchase of Service Credits Transfer Guide ("Guide"), contact Service Provider at
1-866-657-3327 or visit the website at empower.com/njplans.
●
Use black or blue ink when completing this form.
A
What is my personal information? (Continue to the next section after completing.)
Account extension, if applicable, identifies funds
transferred to a beneficiary due to participant's
death, alternate payee due to divorce or a participant
with multiple accounts.
- -
Account Extension
Social Security Number or Taxpayer Identification Number
(Must provide all 9 digits)
Last Name First Name M.I.
(The name provided MUST match the name on file with Service Provider.)
Email Address
Division/Payroll Center
Select One (Required):
I am a U.S. Citizen or U.S. Resident Alien.
I am a Non-Resident Alien or Other.
Required - Provide Country of Residence:
(See Instructions for IRS Form W-8BEN
information.)
/ /
Date of Birth (mm/dd/yyyy)
( )
Daytime Phone Number
( )
Alternate Phone Number
B
How much am I requesting? (Continue to the next section after completing.)
Purchase of Service Credits
(Non-Roth) Amount: $_______________ (Enter the requested amount - Any amount up to and including the amount shown on the Notification of Eligibility/
Acceptance letter. Any applicable Plan withdrawal fees and optional delivery fees will be added to the requested amount.)
I must include the Notification of Eligibility/Acceptance letter from my employer's governmental defined benefit plan with my completed
Purchase of Service Credits Transfer form.
C
To whom do I want my transfer payable and where should it be sent? (Continue to the next section after completing.)
Name/Trustee of Defined Benefit Plan - Required (To whom the check is made payable)
Mailing Address City/State/Zip Code
( )
Defined Benefit Plan Identification or Account Number Phone Number
D
How do I want my transfer delivered? (Continue to the next section after completing.)
Select One - Delivery of payment is based on completion of the withdrawal process, which includes
receipt of a complete request in good order and additional/required information from my employer.
●
If no option is selected, all transactions will be sent by United States Postal Service ("USPS") regular mail.
●
If I would like to make a change to what I previously selected, I must cross out and initial the change(s). If I do not initial all changes,
all transactions will be sent by USPS regular mail.
Purchase of Service Credits Transfer Request
Governmental 457(b) Plan
STD FPRCRD ][05/13/24)( 524954-01 WITHDRAWAL
NO_GRPG 52478/][GU37)(/][DIXK
DOC ID: 25212233)(
Page 1 of 4
NEW JERSEY STATE EMPLOYEES DEFERRED COMPENSATION PLAN 524954-01
When would I use this form?
When I am requesting a transfer to purchase permissible service credits with my employer's governmental defined benefit plan.
●
Please note that this withdrawal request may be subject to an administrative review period prior to processing and the investments in your account
will not be sold until the withdrawal is processed. The administrative review period may take several business days. Note that your investments may
fluctuate with market performance so you may want to redirect or diversify those investments prior to making a withdrawal request. If you initiate a
fund transfer during the administrative review period, it may delay the processing of your withdrawal. If you want to make changes to the investments
in your account prior to withdrawal, please contact Service Provider or access your account online.
Additional Information
●
Return Instructions for this form are in Section F.
●
By logging into my account on the website at empower.com/njplans, I may track the status of this request.
●
For questions regarding this form, refer to the attached Purchase of Service Credits Transfer Guide ("Guide"), contact Service Provider at
1-866-657-3327 or visit the website at empower.com/njplans.
●
Use black or blue ink when completing this form.
A
What is my personal information? (Continue to the next section after completing.)
Account extension, if applicable, identifies funds
transferred to a beneficiary due to participant's
death, alternate payee due to divorce or a participant
with multiple accounts.
- -
Account Extension
Social Security Number or Taxpayer Identification Number
(Must provide all 9 digits)
Last Name First Name M.I.
(The name provided MUST match the name on file with Service Provider.)
Email Address
Division/Payroll Center
Select One
(Required):
I am a U.S. Citizen or U.S. Resident Alien.
I am a Non-Resident Alien or Other.
Required - Provide Country of Residence:
(See Instructions for IRS Form W-8BEN
information.)
/ /
Date of Birth
(mm/dd/yyyy)
( )
Daytime Phone Number
( )
Alternate Phone Number
B
How much am I requesting? (Continue to the next section after completing.)
Purchase of Service Credits
(Non-Roth) Amount: $_______________ (Enter the requested amount - Any amount up to and including the amount shown on the Notification of Eligibility/
Acceptance letter. Any applicable Plan withdrawal fees and optional delivery fees will be added to the requested amount.)
I must include the Notification of Eligibility/Acceptance letter from my employer's governmental defined benefit plan with my completed
Purchase of Service Credits Transfer form.
C
To whom do I want my transfer payable and where should it be sent? (Continue to the next section after completing.)
Name/Trustee of Defined Benefit Plan - Required (To whom the check is made payable)
Mailing Address City/State/Zip Code
( )
Defined Benefit Plan Identification or Account Number Phone Number
D
How do I want my transfer delivered? (Continue to the next section after completing.)
Select One - Delivery of payment is based on completion of the withdrawal process, which includes
receipt of a complete request in good order and
additional/required information from my employer.
●
If no option is selected, all transactions will be sent by United States Postal Service ("USPS") regular mail.
●
If I would like to make a change to what I previously selected, I must cross out and initial the change(s). If I do not initial all changes,
all transactions will be sent by USPS regular mail.
Indicate Retirement System (check one)
q
Teachers Pension and Annuity Fund
q
Police and Firemens Retirement System
q
Public Employees Retirement System
q
State Police Retirement System
q
Judicial Retirement System
Sent to: State of New Jersey • Division of Pensions & Benets, Attention: Cash Receipts, P.O. Box 295, Trenton, NJ 08625-0295
Membership Number ___________________________
524954-01
Last Name First Name M.I. Social Security Number Number
STD FPRCRD ][05/13/24)( 524954-01 WITHDRAWAL
NO_GRPG 52478/][GU37)(/][DIXK
DOC ID: 25212233)(
Page 2 of 4
D
How do I want my transfer delivered? (Continue to the next section after completing.)
Select One - Delivery of payment is based on completion of the withdrawal process, which includes
receipt of a complete request in good order and additional/required information from my employer.
Check by USPS Regular Mail
●
Estimated delivery time is 7-10 business days
●
No additional charge
Check by Express Delivery
●
Estimated delivery time is 1-2 business days
●
A non-refundable charge of up to $25.00 will be deducted, in addition to any withdrawal fees, for each transaction, which will be added to
the purchase of service credit transfer amount requested.
●
Available for delivery, Monday - Friday, with no signature required upon delivery
●
If address is a P.O. Box, check will be sent by USPS Priority Mail and estimated delivery time is 2-3 business days.
E
Signatures and Consent (Signatures must be on the lines provided.) (After receiving ALL required signatures, continue to the next section.)
My Consent (Please sign on the ‘My Signature’ line below.)
I acknowledge that I have read, understand and agree to all pages of this Purchase of Service Credits Transfer Request and the Purchase of
Service Credits Transfer Guide and affirm that all information that I have provided is true and correct. Pursuant to the enclosed Notification of
Eligibility/Acceptance letter from my employer’s governmental defined benefit plan, I hereby authorize the transfer of deferred (pre-tax) funds in the
amount indicated above from my Governmental 457(b) Plan for the purpose of purchasing retirement service credits. I understand the following:
●
Funds may impose redemption fees on certain transfers, redemptions or exchanges if assets are held less than the period stated in the fund's
prospectus or other disclosure documents. I will refer to the fund's prospectus and/or disclosure documents for more information.
●
Under penalty of perjury, I certify that the U.S. Social Security number or U.S. Taxpayer Identification number I have provided in Section A is
correct. I am a U.S. person if I marked the U.S. Citizen or U.S. Resident Alien box in Section A of this form.
●
Additional authentication may be necessary before my withdrawal is processed and/or payment released.
●
My withdrawal may be subject to fees and/or loss of interest based upon my investment options, my length of time in the Plan and
other possible considerations. If I have not been advised of the fees and risks associated with my withdrawal, I may contact Service
Provider for a withdrawal quote at 1-866-657-3327.
Any person who presents a false or fraudulent claim is subject to criminal and civil penalties.
My Signature Date (Required)
A handwritten signature is required on this form. An electronic signature will not be accepted and will result in a significant delay.
My Authorized Plan Administrator Signature (Please sign on the 'Authorized Plan Administrator Signature' line below.)
I certify that this request is in compliance with applicable Plan provisions and federal law and that the participant has received from the Plan any
notices required by law. I approve this transfer as it is presented on this form.
I represent that I am an authorized signer on behalf of the above-named Plan and have an authority to instruct Service Provider to process this form.
Authorized
Plan Administrator Signature Date (Required)
A handwritten signature is required on this form. An electronic signature will not be accepted and will result in a significant delay.
Print Full Name
F
Where should I send this form?
After all signatures have been obtained, this form and a copy of the Notification of Eligibility/Acceptance letter can be
Uploaded Electronically:
Login to account at
empower.com/njplans
Click on Upload Documents to submit
OR Sent Regular Mail to:
Empower
PO Box 56025
Boston, MA 02205-6025
OR Sent Express Mail to:
Empower
8515 E. Orchard Road
Greenwood Village, CO 80111
We will not accept hand delivered forms at Express Mail addresses.
The group variable annuity insurance products are issued through Empower Annuity Insurance Company, Hartford, CT and distributed through Empower
Financial Services, Inc., (EFSI). Both are Empower companies and each organization is solely responsible for its financial condition and contractual
obligations. Annuity contracts contain exclusions, limitations, reductions of benefits and terms for keeping them in force. The annuity or certain of its
investment options or features may not be available in all states. Policy forms currently available include DC- 08-TGWB-2011, ALC-408-TGWB-2011-NR,
ALC-408-TGWB-2011-ROTH, IND-IFX-TGWB-2013-NR, IND-IFX-TGWB-2013-ROTH or state variation thereof.
You could lose money by investing in money market investments. Although they seek to preserve the value of your investment at $1 or $10.00 per share
(see the prospectus), there is no guarantee they will. An investment in a money market investment is not insured or guaranteed by the Federal Deposit
Insurance Corporation or any other government agency. The money market investment’s sponsor has no legal obligation to provide financial support to
the portfolio, and you should not expect that the sponsor will provide financial support to the portfolio at any time. The yield quotation more closely reflects
the current earnings of the portfolio than the total return quotation.
DAES/MANUAL/SR 13644521
Page 2 of 5
524954-01
Last Name First Name M.I. Social Security Number Number
STD FPRCRD ][05/13/24)( 524954-01 WITHDRAWAL
NO_GRPG 52478/][GU37)(/][DIXK
DOC ID: 25212233)(
Page 2 of 4
D
How do I want my transfer delivered? (Continue to the next section after completing.)
Select One - Delivery of payment is based on completion of the withdrawal process, which includes
receipt of a complete request in good order and
additional/required information from my employer.
Check by USPS Regular Mail
●
Estimated delivery time is 7-10 business days
●
No additional charge
Check by Express Delivery
●
Estimated delivery time is 1-2 business days
●
A non-refundable charge of up to $25.00 will be deducted, in addition to any withdrawal fees, for each transaction, which will be added to
the purchase of service credit transfer amount requested.
●
Available for delivery, Monday - Friday, with no signature required upon delivery
●
If address is a P.O. Box, check will be sent by USPS Priority Mail and estimated delivery time is 2-3 business days.
E
Signatures and Consent (Signatures must be on the lines provided.) (After receiving ALL required signatures, continue to the next section.)
My Consent (Please sign on the ‘My Signature’ line below.)
I acknowledge that I have read, understand and agree to all pages of this Purchase of Service Credits Transfer Request and the Purchase of
Service Credits Transfer Guide and affirm that all information that I have provided is true and correct. Pursuant to the enclosed Notification of
Eligibility/Acceptance letter from my employer’s governmental defined benefit plan, I hereby authorize the transfer of deferred (pre-tax) funds in the
amount indicated above from my Governmental 457(b) Plan for the purpose of purchasing retirement service credits. I understand the following:
●
Funds may impose redemption fees on certain transfers, redemptions or exchanges if assets are held less than the period stated in the fund's
prospectus or other disclosure documents. I will refer to the fund's prospectus and/or disclosure documents for more information.
●
Under penalty of perjury, I certify that the U.S. Social Security number or U.S. Taxpayer Identification number I have provided in Section A is
correct. I am a U.S. person if I marked the U.S. Citizen or U.S. Resident Alien box in Section A of this form.
●
Additional authentication may be necessary before my withdrawal is processed and/or payment released.
●
My withdrawal may be subject to fees and/or loss of interest based upon my investment options, my length of time in the Plan and
other possible considerations. If I have not been advised of the fees and risks associated with my withdrawal, I may contact Service
Provider for a withdrawal quote at 1-866-657-3327.
Any person who presents a false or fraudulent claim is subject to criminal and civil penalties.
My Signature Date (Required)
A handwritten signature is required on this form. An electronic signature will not be accepted and will result in a significant delay.
My Authorized Plan Administrator Signature (Please sign on the 'Authorized Plan Administrator Signature' line below.)
I certify that this request is in compliance with applicable Plan provisions and federal law and that the participant has received from the Plan any
notices required by law. I approve this transfer as it is presented on this form.
I represent that I am an authorized signer on behalf of the above-named Plan and have an authority to instruct Service Provider to process this form.
Authorized
Plan Administrator Signature Date (Required)
A handwritten signature is required on this form. An electronic signature will not be accepted and will result in a significant delay.
Print Full Name
F
Where should I send this form?
After all signatures have been obtained, this form and a copy of the Notification of Eligibility/Acceptance letter can be
Uploaded Electronically:
Login to account at
empower.com/njplans
Click on Upload Documents to submit
OR Sent Regular Mail to:
Empower
PO Box 56025
Boston, MA 02205-6025
OR Sent Express Mail to:
Empower
8515 E. Orchard Road
Greenwood Village, CO 80111
We will not accept hand delivered forms at Express Mail addresses.
The group variable annuity insurance products are issued through Empower Annuity Insurance Company, Hartford, CT and distributed through Empower
Financial Services, Inc., (EFSI). Both are Empower companies and each organization is solely responsible for its financial condition and contractual
obligations. Annuity contracts contain exclusions, limitations, reductions of benefits and terms for keeping them in force. The annuity or certain of its
investment options or features may not be available in all states. Policy forms currently available include DC- 08-TGWB-2011, ALC-408-TGWB-2011-NR,
ALC-408-TGWB-2011-ROTH, IND-IFX-TGWB-2013-NR, IND-IFX-TGWB-2013-ROTH or state variation thereof.
You could lose money by investing in money market investments. Although they seek to preserve the value of your investment at $1 or $10.00 per share
(see the prospectus), there is no guarantee they will. An investment in a money market investment is not insured or guaranteed by the Federal Deposit
Insurance Corporation or any other government agency. The money market investment’s sponsor has no legal obligation to provide financial support to
the portfolio, and you should not expect that the sponsor will provide financial support to the portfolio at any time. The yield quotation more closely reflects
the current earnings of the portfolio than the total return quotation.
524954-01
Last Name First Name M.I. Social Security Number Number
STD FPRCRD ][05/13/24)( 524954-01 WITHDRAWAL
NO_GRPG 52478/][GU37)(/][DIXK
DOC ID: 25212233)(
Page 2 of 4
D
How do I want my transfer delivered? (Continue to the next section after completing.)
Select One - Delivery of payment is based on completion of the withdrawal process, which includes
receipt of a complete request in good order and additional/required information from my employer.
Check by USPS Regular Mail
●
Estimated delivery time is 7-10 business days
●
No additional charge
Check by Express Delivery
●
Estimated delivery time is 1-2 business days
●
A non-refundable charge of up to $25.00 will be deducted, in addition to any withdrawal fees, for each transaction, which will be added to
the purchase of service credit transfer amount requested.
●
Available for delivery, Monday - Friday, with no signature required upon delivery
●
If address is a P.O. Box, check will be sent by USPS Priority Mail and estimated delivery time is 2-3 business days.
E
Signatures and Consent (Signatures must be on the lines provided.) (After receiving ALL required signatures, continue to the next section.)
My Consent (Please sign on the ‘My Signature’ line below.)
I acknowledge that I have read, understand and agree to all pages of this Purchase of Service Credits Transfer Request and the Purchase of
Service Credits Transfer Guide and affirm that all information that I have provided is true and correct. Pursuant to the enclosed Notification of
Eligibility/Acceptance letter from my employer’s governmental defined benefit plan, I hereby authorize the transfer of deferred (pre-tax) funds in the
amount indicated above from my Governmental 457(b) Plan for the purpose of purchasing retirement service credits. I understand the following:
●
Funds may impose redemption fees on certain transfers, redemptions or exchanges if assets are held less than the period stated in the fund's
prospectus or other disclosure documents. I will refer to the fund's prospectus and/or disclosure documents for more information.
●
Under penalty of perjury, I certify that the U.S. Social Security number or U.S. Taxpayer Identification number I have provided in Section A is
correct. I am a U.S. person if I marked the U.S. Citizen or U.S. Resident Alien box in Section A of this form.
●
Additional authentication may be necessary before my withdrawal is processed and/or payment released.
●
My withdrawal may be subject to fees and/or loss of interest based upon my investment options, my length of time in the Plan and
other possible considerations. If I have not been advised of the fees and risks associated with my withdrawal, I may contact Service
Provider for a withdrawal quote at 1-866-657-3327.
Any person who presents a false or fraudulent claim is subject to criminal and civil penalties.
My Signature Date (Required)
A handwritten signature is required on this form. An electronic signature will not be accepted and will result in a significant delay.
My Authorized Plan Administrator Signature (Please sign on the 'Authorized Plan Administrator Signature' line below.)
I certify that this request is in compliance with applicable Plan provisions and federal law and that the participant has received from the Plan any
notices required by law. I approve this transfer as it is presented on this form.
I represent that I am an authorized signer on behalf of the above-named Plan and have an authority to instruct Service Provider to process this form.
Authorized
Plan Administrator Signature Date (Required)
A handwritten signature is required on this form. An electronic signature will not be accepted and will result in a significant delay.
Print Full Name
F
Where should I send this form?
After all signatures have been obtained, this form and a copy of the Notification of Eligibility/Acceptance letter can be
Uploaded Electronically:
Login to account at
empower.com/njplans
Click on Upload Documents to submit
OR Sent Regular Mail to:
Empower
PO Box 56025
Boston, MA 02205-6025
OR Sent Express Mail to:
Empower
8515 E. Orchard Road
Greenwood Village, CO 80111
We will not accept hand delivered forms at Express Mail addresses.
The group variable annuity insurance products are issued through Empower Annuity Insurance Company, Hartford, CT and distributed through Empower
Financial Services, Inc., (EFSI). Both are Empower companies and each organization is solely responsible for its financial condition and contractual
obligations. Annuity contracts contain exclusions, limitations, reductions of benefits and terms for keeping them in force. The annuity or certain of its
investment options or features may not be available in all states. Policy forms currently available include DC- 08-TGWB-2011, ALC-408-TGWB-2011-NR,
ALC-408-TGWB-2011-ROTH, IND-IFX-TGWB-2013-NR, IND-IFX-TGWB-2013-ROTH or state variation thereof.
You could lose money by investing in money market investments. Although they seek to preserve the value of your investment at $1 or $10.00 per share
(see the prospectus), there is no guarantee they will. An investment in a money market investment is not insured or guaranteed by the Federal Deposit
Insurance Corporation or any other government agency. The money market investment’s sponsor has no legal obligation to provide financial support to
the portfolio, and you should not expect that the sponsor will provide financial support to the portfolio at any time. The yield quotation more closely reflects
the current earnings of the portfolio than the total return quotation.
DAES/MANUAL/SR 13644521
Page 2 of 5
524954-01
Last Name First Name M.I. Social Security Number Number
STD FPRCRD ][05/13/24)( 524954-01 WITHDRAWAL
NO_GRPG 52478/][GU37)(/][DIXK
DOC ID: 25212233)(
Page 2 of 4
D
How do I want my transfer delivered? (Continue to the next section after completing.)
Select One - Delivery of payment is based on completion of the withdrawal process, which includes
receipt of a complete request in good order and
additional/required information from my employer.
Check by USPS Regular Mail
●
Estimated delivery time is 7-10 business days
●
No additional charge
Check by Express Delivery
●
Estimated delivery time is 1-2 business days
●
A non-refundable charge of up to $25.00 will be deducted, in addition to any withdrawal fees, for each transaction, which will be added to
the purchase of service credit transfer amount requested.
●
Available for delivery, Monday - Friday, with no signature required upon delivery
●
If address is a P.O. Box, check will be sent by USPS Priority Mail and estimated delivery time is 2-3 business days.
E
Signatures and Consent (Signatures must be on the lines provided.) (After receiving ALL required signatures, continue to the next section.)
My Consent (Please sign on the ‘My Signature’ line below.)
I acknowledge that I have read, understand and agree to all pages of this Purchase of Service Credits Transfer Request and the Purchase of
Service Credits Transfer Guide and affirm that all information that I have provided is true and correct. Pursuant to the enclosed Notification of
Eligibility/Acceptance letter from my employer’s governmental defined benefit plan, I hereby authorize the transfer of deferred (pre-tax) funds in the
amount indicated above from my Governmental 457(b) Plan for the purpose of purchasing retirement service credits. I understand the following:
●
Funds may impose redemption fees on certain transfers, redemptions or exchanges if assets are held less than the period stated in the fund's
prospectus or other disclosure documents. I will refer to the fund's prospectus and/or disclosure documents for more information.
●
Under penalty of perjury, I certify that the U.S. Social Security number or U.S. Taxpayer Identification number I have provided in Section A is
correct. I am a U.S. person if I marked the U.S. Citizen or U.S. Resident Alien box in Section A of this form.
●
Additional authentication may be necessary before my withdrawal is processed and/or payment released.
●
My withdrawal may be subject to fees and/or loss of interest based upon my investment options, my length of time in the Plan and
other possible considerations. If I have not been advised of the fees and risks associated with my withdrawal, I may contact Service
Provider for a withdrawal quote at 1-866-657-3327.
Any person who presents a false or fraudulent claim is subject to criminal and civil penalties.
My Signature Date (Required)
A handwritten signature is required on this form. An electronic signature will not be accepted and will result in a significant delay.
My Authorized Plan Administrator Signature (Please sign on the 'Authorized Plan Administrator Signature' line below.)
I certify that this request is in compliance with applicable Plan provisions and federal law and that the participant has received from the Plan any
notices required by law. I approve this transfer as it is presented on this form.
I represent that I am an authorized signer on behalf of the above-named Plan and have an authority to instruct Service Provider to process this form.
Authorized
Plan Administrator Signature Date (Required)
A handwritten signature is required on this form. An electronic signature will not be accepted and will result in a significant delay.
Print Full Name
F
Where should I send this form?
After all signatures have been obtained, this form and a copy of the Notification of Eligibility/Acceptance letter can be
Uploaded Electronically:
Login to account at
empower.com/njplans
Click on Upload Documents to submit
OR Sent Regular Mail to:
Empower
PO Box 56025
Boston, MA 02205-6025
OR Sent Express Mail to:
Empower
8515 E. Orchard Road
Greenwood Village, CO 80111
We will not accept hand delivered forms at Express Mail addresses.
The group variable annuity insurance products are issued through Empower Annuity Insurance Company, Hartford, CT and distributed through Empower
Financial Services, Inc., (EFSI). Both are Empower companies and each organization is solely responsible for its financial condition and contractual
obligations. Annuity contracts contain exclusions, limitations, reductions of benefits and terms for keeping them in force. The annuity or certain of its
investment options or features may not be available in all states. Policy forms currently available include DC- 08-TGWB-2011, ALC-408-TGWB-2011-NR,
ALC-408-TGWB-2011-ROTH, IND-IFX-TGWB-2013-NR, IND-IFX-TGWB-2013-ROTH or state variation thereof.
You could lose money by investing in money market investments. Although they seek to preserve the value of your investment at $1 or $10.00 per share
(see the prospectus), there is no guarantee they will. An investment in a money market investment is not insured or guaranteed by the Federal Deposit
Insurance Corporation or any other government agency. The money market investment’s sponsor has no legal obligation to provide financial support to
the portfolio, and you should not expect that the sponsor will provide financial support to the portfolio at any time. The yield quotation more closely reflects
the current earnings of the portfolio than the total return quotation.
524954-01
Last Name First Name M.I. Social Security Number Number
STD FPRCRD ][05/13/24)( 524954-01 WITHDRAWAL
NO_GRPG 52478/][GU37)(/][DIXK
DOC ID: 25212233)(
Page 2 of 4
D
How do I want my transfer delivered? (Continue to the next section after completing.)
Select One - Delivery of payment is based on completion of the withdrawal process, which includes
receipt of a complete request in good order and additional/required information from my employer.
Check by USPS Regular Mail
●
Estimated delivery time is 7-10 business days
●
No additional charge
Check by Express Delivery
●
Estimated delivery time is 1-2 business days
●
A non-refundable charge of up to $25.00 will be deducted, in addition to any withdrawal fees, for each transaction, which will be added to
the purchase of service credit transfer amount requested.
●
Available for delivery, Monday - Friday, with no signature required upon delivery
●
If address is a P.O. Box, check will be sent by USPS Priority Mail and estimated delivery time is 2-3 business days.
E
Signatures and Consent (Signatures must be on the lines provided.) (After receiving ALL required signatures, continue to the next section.)
My Consent (Please sign on the ‘My Signature’ line below.)
I acknowledge that I have read, understand and agree to all pages of this Purchase of Service Credits Transfer Request and the Purchase of
Service Credits Transfer Guide and affirm that all information that I have provided is true and correct. Pursuant to the enclosed Notification of
Eligibility/Acceptance letter from my employer’s governmental defined benefit plan, I hereby authorize the transfer of deferred (pre-tax) funds in the
amount indicated above from my Governmental 457(b) Plan for the purpose of purchasing retirement service credits. I understand the following:
●
Funds may impose redemption fees on certain transfers, redemptions or exchanges if assets are held less than the period stated in the fund's
prospectus or other disclosure documents. I will refer to the fund's prospectus and/or disclosure documents for more information.
●
Under penalty of perjury, I certify that the U.S. Social Security number or U.S. Taxpayer Identification number I have provided in Section A is
correct. I am a U.S. person if I marked the U.S. Citizen or U.S. Resident Alien box in Section A of this form.
●
Additional authentication may be necessary before my withdrawal is processed and/or payment released.
●
My withdrawal may be subject to fees and/or loss of interest based upon my investment options, my length of time in the Plan and
other possible considerations. If I have not been advised of the fees and risks associated with my withdrawal, I may contact Service
Provider for a withdrawal quote at 1-866-657-3327.
Any person who presents a false or fraudulent claim is subject to criminal and civil penalties.
My Signature Date (Required)
A handwritten signature is required on this form. An electronic signature will not be accepted and will result in a significant delay.
My Authorized Plan Administrator Signature (Please sign on the 'Authorized Plan Administrator Signature' line below.)
I certify that this request is in compliance with applicable Plan provisions and federal law and that the participant has received from the Plan any
notices required by law. I approve this transfer as it is presented on this form.
I represent that I am an authorized signer on behalf of the above-named Plan and have an authority to instruct Service Provider to process this form.
Authorized
Plan Administrator Signature Date (Required)
A handwritten signature is required on this form. An electronic signature will not be accepted and will result in a significant delay.
Print Full Name
F
Where should I send this form?
After all signatures have been obtained, this form and a copy of the Notification of Eligibility/Acceptance letter can be
Uploaded Electronically:
Login to account at
empower.com/njplans
Click on Upload Documents to submit
OR Sent Regular Mail to:
Empower
PO Box 56025
Boston, MA 02205-6025
OR Sent Express Mail to:
Empower
8515 E. Orchard Road
Greenwood Village, CO 80111
We will not accept hand delivered forms at Express Mail addresses.
The group variable annuity insurance products are issued through Empower Annuity Insurance Company, Hartford, CT and distributed through Empower
Financial Services, Inc., (EFSI). Both are Empower companies and each organization is solely responsible for its financial condition and contractual
obligations. Annuity contracts contain exclusions, limitations, reductions of benefits and terms for keeping them in force. The annuity or certain of its
investment options or features may not be available in all states. Policy forms currently available include DC- 08-TGWB-2011, ALC-408-TGWB-2011-NR,
ALC-408-TGWB-2011-ROTH, IND-IFX-TGWB-2013-NR, IND-IFX-TGWB-2013-ROTH or state variation thereof.
You could lose money by investing in money market investments. Although they seek to preserve the value of your investment at $1 or $10.00 per share
(see the prospectus), there is no guarantee they will. An investment in a money market investment is not insured or guaranteed by the Federal Deposit
Insurance Corporation or any other government agency. The money market investment’s sponsor has no legal obligation to provide financial support to
the portfolio, and you should not expect that the sponsor will provide financial support to the portfolio at any time. The yield quotation more closely reflects
the current earnings of the portfolio than the total return quotation.
DAES/MANUAL/SR 13644521
Page 3 of 5
524954-01
Last Name First Name M.I. Social Security Number Number
STD FPRCRD ][07/08/24)( 524954-01 WITHDRAWAL
NO_GRPG 52478/][GU37)(/][DAES
DOC ID: 31027669)(
Page 3 of 5
F
Where should I send this form?
Participant forward this form to:
State of New Jersey
Division of Pensions and Benefits
P.O. Box 295
Trenton, NJ 08625-0295
Fax:
After all signatures have been obtained, this form and a copy of the Notification of Eligibility/Acceptance letter can be
Sent Regular Mail to:
Empower
PO Box 56025
Boston, MA 02205-6025
OR
Sent Express Mail to:
Empower
8515 E. Orchard Road
Greenwood Village, CO 80111
We will not accept hand delivered forms at Express Mail addresses.
The group variable annuity insurance products are issued through Empower Annuity Insurance Company, Hartford, CT and distributed through Empower
Financial Services, Inc., (EFSI). Both are Empower companies and each organization is solely responsible for its financial condition and contractual
obligations. Annuity contracts contain exclusions, limitations, reductions of benefits and terms for keeping them in force. The annuity or certain of its
investment options or features may not be available in all states. Policy forms currently available include DC- 08-TGWB-2011, ALC-408-TGWB-2011-NR,
ALC-408-TGWB-2011-ROTH, IND-IFX-TGWB-2013-NR, IND-IFX-TGWB-2013-ROTH or state variation thereof.
You could lose money by investing in money market investments. Although they seek to preserve the value of your investment at $1 or $10.00 per share
(see the prospectus), there is no guarantee they will. An investment in a money market investment is not insured or guaranteed by the Federal Deposit
Insurance Corporation or any other government agency. The money market investment’s sponsor has no legal obligation to provide financial support to
the portfolio, and you should not expect that the sponsor will provide financial support to the portfolio at any time. The yield quotation more closely reflects
the current earnings of the portfolio than the total return quotation.
524954-01
Last Name First Name M.I. Social Security Number Number
STD FPRCRD ][07/08/24)( 524954-01 WITHDRAWAL
NO_GRPG 52478/][GU37)(/][DAES
DOC ID: 31027669)(
Page 3 of 5
F
Where should I send this form?
Participant forward this form to:
State of New Jersey
Division of Pensions and Benefits
P.O. Box 295
Trenton, NJ 08625-0295
Fax:
After all signatures have been obtained, this form and a copy of the Notification of Eligibility/Acceptance letter can be
Sent Regular Mail to:
Empower
PO Box 56025
Boston, MA 02205-6025
OR
Sent Express Mail to:
Empower
8515 E. Orchard Road
Greenwood Village, CO 80111
We will not accept hand delivered forms at Express Mail addresses.
The group variable annuity insurance products are issued through Empower Annuity Insurance Company, Hartford, CT and distributed through Empower
Financial Services, Inc., (EFSI). Both are Empower companies and each organization is solely responsible for its financial condition and contractual
obligations. Annuity contracts contain exclusions, limitations, reductions of benefits and terms for keeping them in force. The annuity or certain of its
investment options or features may not be available in all states. Policy forms currently available include DC- 08-TGWB-2011, ALC-408-TGWB-2011-NR,
ALC-408-TGWB-2011-ROTH, IND-IFX-TGWB-2013-NR, IND-IFX-TGWB-2013-ROTH or state variation thereof.
You could lose money by investing in money market investments. Although they seek to preserve the value of your investment at $1 or $10.00 per share
(see the prospectus), there is no guarantee they will. An investment in a money market investment is not insured or guaranteed by the Federal Deposit
Insurance Corporation or any other government agency. The money market investment’s sponsor has no legal obligation to provide financial support to
the portfolio, and you should not expect that the sponsor will provide financial support to the portfolio at any time. The yield quotation more closely reflects
the current earnings of the portfolio than the total return quotation.
609-633-1696
ATTN: Cash Receipts
524954-01
Last Name First Name M.I. Social Security Number Number
STD FPRCRD ][05/13/24)( 524954-01 WITHDRAWAL
NO_GRPG 52478/][GU37)(/][DIXK
DOC ID: 25212233)(
Page 2 of 4
D
How do I want my transfer delivered? (Continue to the next section after completing.)
Select One - Delivery of payment is based on completion of the withdrawal process, which includes
receipt of a complete request in good order and additional/required information from my employer.
Check by USPS Regular Mail
●
Estimated delivery time is 7-10 business days
●
No additional charge
Check by Express Delivery
●
Estimated delivery time is 1-2 business days
●
A non-refundable charge of up to $25.00 will be deducted, in addition to any withdrawal fees, for each transaction, which will be added to
the purchase of service credit transfer amount requested.
●
Available for delivery, Monday - Friday, with no signature required upon delivery
●
If address is a P.O. Box, check will be sent by USPS Priority Mail and estimated delivery time is 2-3 business days.
E
Signatures and Consent (Signatures must be on the lines provided.) (After receiving ALL required signatures, continue to the next section.)
My Consent (Please sign on the ‘My Signature’ line below.)
I acknowledge that I have read, understand and agree to all pages of this Purchase of Service Credits Transfer Request and the Purchase of
Service Credits Transfer Guide and affirm that all information that I have provided is true and correct. Pursuant to the enclosed Notification of
Eligibility/Acceptance letter from my employer’s governmental defined benefit plan, I hereby authorize the transfer of deferred (pre-tax) funds in the
amount indicated above from my Governmental 457(b) Plan for the purpose of purchasing retirement service credits. I understand the following:
●
Funds may impose redemption fees on certain transfers, redemptions or exchanges if assets are held less than the period stated in the fund's
prospectus or other disclosure documents. I will refer to the fund's prospectus and/or disclosure documents for more information.
●
Under penalty of perjury, I certify that the U.S. Social Security number or U.S. Taxpayer Identification number I have provided in Section A is
correct. I am a U.S. person if I marked the U.S. Citizen or U.S. Resident Alien box in Section A of this form.
●
Additional authentication may be necessary before my withdrawal is processed and/or payment released.
●
My withdrawal may be subject to fees and/or loss of interest based upon my investment options, my length of time in the Plan and
other possible considerations. If I have not been advised of the fees and risks associated with my withdrawal, I may contact Service
Provider for a withdrawal quote at 1-866-657-3327.
Any person who presents a false or fraudulent claim is subject to criminal and civil penalties.
My Signature Date (Required)
A handwritten signature is required on this form. An electronic signature will not be accepted and will result in a significant delay.
My Authorized Plan Administrator Signature (Please sign on the 'Authorized Plan Administrator Signature' line below.)
I certify that this request is in compliance with applicable Plan provisions and federal law and that the participant has received from the Plan any
notices required by law. I approve this transfer as it is presented on this form.
I represent that I am an authorized signer on behalf of the above-named Plan and have an authority to instruct Service Provider to process this form.
Authorized
Plan Administrator Signature Date (Required)
A handwritten signature is required on this form. An electronic signature will not be accepted and will result in a significant delay.
Print Full Name
F
Where should I send this form?
After all signatures have been obtained, this form and a copy of the Notification of Eligibility/Acceptance letter can be
Uploaded Electronically:
Login to account at
empower.com/njplans
Click on Upload Documents to submit
OR Sent Regular Mail to:
Empower
PO Box 56025
Boston, MA 02205-6025
OR Sent Express Mail to:
Empower
8515 E. Orchard Road
Greenwood Village, CO 80111
We will not accept hand delivered forms at Express Mail addresses.
The group variable annuity insurance products are issued through Empower Annuity Insurance Company, Hartford, CT and distributed through Empower
Financial Services, Inc., (EFSI). Both are Empower companies and each organization is solely responsible for its financial condition and contractual
obligations. Annuity contracts contain exclusions, limitations, reductions of benefits and terms for keeping them in force. The annuity or certain of its
investment options or features may not be available in all states. Policy forms currently available include DC- 08-TGWB-2011, ALC-408-TGWB-2011-NR,
ALC-408-TGWB-2011-ROTH, IND-IFX-TGWB-2013-NR, IND-IFX-TGWB-2013-ROTH or state variation thereof.
You could lose money by investing in money market investments. Although they seek to preserve the value of your investment at $1 or $10.00 per share
(see the prospectus), there is no guarantee they will. An investment in a money market investment is not insured or guaranteed by the Federal Deposit
Insurance Corporation or any other government agency. The money market investment’s sponsor has no legal obligation to provide financial support to
the portfolio, and you should not expect that the sponsor will provide financial support to the portfolio at any time. The yield quotation more closely reflects
the current earnings of the portfolio than the total return quotation.
DAES/MANUAL/SR 13644521
Page 3 of 5
524954-01
Last Name First Name M.I. Social Security Number Number
STD FPRCRD ][07/08/24)( 524954-01 WITHDRAWAL
NO_GRPG 52478/][GU37)(/][DAES
DOC ID: 31027669)(
Page 3 of 5
F
Where should I send this form?
Participant forward this form to:
State of New Jersey
Division of Pensions and Benefits
P.O. Box 295
Trenton, NJ 08625-0295
Fax:
After all signatures have been obtained, this form and a copy of the Notification of Eligibility/Acceptance letter can be
Sent Regular Mail to:
Empower
PO Box 56025
Boston, MA 02205-6025
OR
Sent Express Mail to:
Empower
8515 E. Orchard Road
Greenwood Village, CO 80111
We will not accept hand delivered forms at Express Mail addresses.
The group variable annuity insurance products are issued through Empower Annuity Insurance Company, Hartford, CT and distributed through Empower
Financial Services, Inc., (EFSI). Both are Empower companies and each organization is solely responsible for its financial condition and contractual
obligations. Annuity contracts contain exclusions, limitations, reductions of benefits and terms for keeping them in force. The annuity or certain of its
investment options or features may not be available in all states. Policy forms currently available include DC- 08-TGWB-2011, ALC-408-TGWB-2011-NR,
ALC-408-TGWB-2011-ROTH, IND-IFX-TGWB-2013-NR, IND-IFX-TGWB-2013-ROTH or state variation thereof.
You could lose money by investing in money market investments. Although they seek to preserve the value of your investment at $1 or $10.00 per share
(see the prospectus), there is no guarantee they will. An investment in a money market investment is not insured or guaranteed by the Federal Deposit
Insurance Corporation or any other government agency. The money market investment’s sponsor has no legal obligation to provide financial support to
the portfolio, and you should not expect that the sponsor will provide financial support to the portfolio at any time. The yield quotation more closely reflects
the current earnings of the portfolio than the total return quotation.
524954-01
Last Name First Name M.I. Social Security Number Number
STD FPRCRD ][07/08/24)( 524954-01 WITHDRAWAL
NO_GRPG 52478/][GU37)(/][DAES
DOC ID: 31027669)(
Page 3 of 5
F
Where should I send this form?
Participant forward this form to:
State of New Jersey
Division of Pensions and Benefits
P.O. Box 295
Trenton, NJ 08625-0295
Fax:
After all signatures have been obtained, this form and a copy of the Notification of Eligibility/Acceptance letter can be
Sent Regular Mail to:
Empower
PO Box 56025
Boston, MA 02205-6025
OR
Sent Express Mail to:
Empower
8515 E. Orchard Road
Greenwood Village, CO 80111
We will not accept hand delivered forms at Express Mail addresses.
The group variable annuity insurance products are issued through Empower Annuity Insurance Company, Hartford, CT and distributed through Empower
Financial Services, Inc., (EFSI). Both are Empower companies and each organization is solely responsible for its financial condition and contractual
obligations. Annuity contracts contain exclusions, limitations, reductions of benefits and terms for keeping them in force. The annuity or certain of its
investment options or features may not be available in all states. Policy forms currently available include DC- 08-TGWB-2011, ALC-408-TGWB-2011-NR,
ALC-408-TGWB-2011-ROTH, IND-IFX-TGWB-2013-NR, IND-IFX-TGWB-2013-ROTH or state variation thereof.
You could lose money by investing in money market investments. Although they seek to preserve the value of your investment at $1 or $10.00 per share
(see the prospectus), there is no guarantee they will. An investment in a money market investment is not insured or guaranteed by the Federal Deposit
Insurance Corporation or any other government agency. The money market investment’s sponsor has no legal obligation to provide financial support to
the portfolio, and you should not expect that the sponsor will provide financial support to the portfolio at any time. The yield quotation more closely reflects
the current earnings of the portfolio than the total return quotation.
609-633-1696
ATTN: Cash Receipts
524954-01
Last Name First Name M.I. Social Security Number Number
STD FPRCRD ][05/13/24)( 524954-01 WITHDRAWAL
NO_GRPG 52478/][GU37)(/][DIXK
DOC ID: 25212233)(
Page 2 of 4
D
How do I want my transfer delivered? (Continue to the next section after completing.)
Select One - Delivery of payment is based on completion of the withdrawal process, which includes
receipt of a complete request in good order and additional/required information from my employer.
Check by USPS Regular Mail
●
Estimated delivery time is 7-10 business days
●
No additional charge
Check by Express Delivery
●
Estimated delivery time is 1-2 business days
●
A non-refundable charge of up to $25.00 will be deducted, in addition to any withdrawal fees, for each transaction, which will be added to
the purchase of service credit transfer amount requested.
●
Available for delivery, Monday - Friday, with no signature required upon delivery
●
If address is a P.O. Box, check will be sent by USPS Priority Mail and estimated delivery time is 2-3 business days.
E
Signatures and Consent (Signatures must be on the lines provided.) (After receiving ALL required signatures, continue to the next section.)
My Consent (Please sign on the ‘My Signature’ line below.)
I acknowledge that I have read, understand and agree to all pages of this Purchase of Service Credits Transfer Request and the Purchase of
Service Credits Transfer Guide and affirm that all information that I have provided is true and correct. Pursuant to the enclosed Notification of
Eligibility/Acceptance letter from my employer’s governmental defined benefit plan, I hereby authorize the transfer of deferred (pre-tax) funds in the
amount indicated above from my Governmental 457(b) Plan for the purpose of purchasing retirement service credits. I understand the following:
●
Funds may impose redemption fees on certain transfers, redemptions or exchanges if assets are held less than the period stated in the fund's
prospectus or other disclosure documents. I will refer to the fund's prospectus and/or disclosure documents for more information.
●
Under penalty of perjury, I certify that the U.S. Social Security number or U.S. Taxpayer Identification number I have provided in Section A is
correct. I am a U.S. person if I marked the U.S. Citizen or U.S. Resident Alien box in Section A of this form.
●
Additional authentication may be necessary before my withdrawal is processed and/or payment released.
●
My withdrawal may be subject to fees and/or loss of interest based upon my investment options, my length of time in the Plan and
other possible considerations. If I have not been advised of the fees and risks associated with my withdrawal, I may contact Service
Provider for a withdrawal quote at 1-866-657-3327.
Any person who presents a false or fraudulent claim is subject to criminal and civil penalties.
My Signature Date (Required)
A handwritten signature is required on this form. An electronic signature will not be accepted and will result in a significant delay.
My Authorized Plan Administrator Signature (Please sign on the 'Authorized Plan Administrator Signature' line below.)
I certify that this request is in compliance with applicable Plan provisions and federal law and that the participant has received from the Plan any
notices required by law. I approve this transfer as it is presented on this form.
I represent that I am an authorized signer on behalf of the above-named Plan and have an authority to instruct Service Provider to process this form.
Authorized
Plan Administrator Signature Date (Required)
A handwritten signature is required on this form. An electronic signature will not be accepted and will result in a significant delay.
Print Full Name
F
Where should I send this form?
After all signatures have been obtained, this form and a copy of the Notification of Eligibility/Acceptance letter can be
Uploaded Electronically:
Login to account at
empower.com/njplans
Click on Upload Documents to submit
OR Sent Regular Mail to:
Empower
PO Box 56025
Boston, MA 02205-6025
OR Sent Express Mail to:
Empower
8515 E. Orchard Road
Greenwood Village, CO 80111
We will not accept hand delivered forms at Express Mail addresses.
The group variable annuity insurance products are issued through Empower Annuity Insurance Company, Hartford, CT and distributed through Empower
Financial Services, Inc., (EFSI). Both are Empower companies and each organization is solely responsible for its financial condition and contractual
obligations. Annuity contracts contain exclusions, limitations, reductions of benefits and terms for keeping them in force. The annuity or certain of its
investment options or features may not be available in all states. Policy forms currently available include DC- 08-TGWB-2011, ALC-408-TGWB-2011-NR,
ALC-408-TGWB-2011-ROTH, IND-IFX-TGWB-2013-NR, IND-IFX-TGWB-2013-ROTH or state variation thereof.
You could lose money by investing in money market investments. Although they seek to preserve the value of your investment at $1 or $10.00 per share
(see the prospectus), there is no guarantee they will. An investment in a money market investment is not insured or guaranteed by the Federal Deposit
Insurance Corporation or any other government agency. The money market investment’s sponsor has no legal obligation to provide financial support to
the portfolio, and you should not expect that the sponsor will provide financial support to the portfolio at any time. The yield quotation more closely reflects
the current earnings of the portfolio than the total return quotation.
DAES/MANUAL/SR 13644521
Page 4 of 5
STD FPRCRD ][05/13/24)( 524954-01 WITHDRAWAL
NO_GRPG 52478/][GU37)(/][DIXK
DOC ID: 25212233)(
Page 3 of 4
Purchase of Service Credits Transfer Guide - Governmental 457(b)
The Purchase of Service Credits Transfer Request
Before completing the form, please note the following information:
●
All pages of the Purchase of Service Credits Transfer Request form ("Transfer Form") must be returned excluding the Purchase of Service Credits
Transfer Guide.
●
Neither this Guide nor this Transfer Form are intended to provide tax or legal advice. In the preparation of this Transfer Form, and where I deem
appropriate, I will seek a consultation with my accountant and/or tax advisor.
●
Empower ("Service Provider") cannot release the funds until my employer confirms that I am entitled to take a transfer from the Plan.
●
If I would like a different withdrawal option other than Purchase of Service Credits, I need to complete either the In-Service Withdrawal
form, if I am still employed with the Employer/Company sponsoring this Plan or the Separation from Employment Withdrawal form, if I am
no longer working for the Employer/Company sponsoring this Plan.
●
If I have more than one account or plan number, I must complete a separate Transfer Form for each account or plan number.
Changes to My Request
●
Any changes to this Transfer Form must be crossed out and initialed. If I do not initial all changes, this Transfer Form may be returned to me for
verification.
Incomplete or Inaccurate Information
●
In the event that any section of this Transfer Form is incomplete or inaccurate, Service Provider may not be able to process the transaction requested
on this Transfer Form. I may be required to complete a new form or provide additional or proper information before the transaction will be processed.
Section A: What is my personal information?
●
All information in this section must be completed.
●
The name provided MUST match the name on file with Service Provider.
●
Personal information will be kept confidential.
●
If I am a non-resident alien, I must attach, to each withdrawal request, a current version of the IRS Form W-8BEN with an original signature and this
must be sent by mail or express delivery. Service Provider cannot accept a fax of this form.
●
I may call 1-800-TAX-FORM (829-3676) or visit irs.gov to obtain a current version of an IRS Form W-8BEN.
Section B: How much am I requesting?
●
I must enter the amount that I would like transferred, up to and including the amount shown on the Notification of Eligibility/Acceptance letter.
●
If my Plan charges any distribution fees or I choose an optional delivery method that has a fee, these will be added to the amount approved for a
transfer, thereby increasing the amount disbursed from my account by the amount of these fees.
Section C: To whom do I want my transfer payable and where should it be sent?
●
It is my responsibility to make sure that the Name/Trustee of the Defined Benefit Plan information provided is accurate. Service Provider is not
responsible for misdirected payments due to an incorrect address.
Section D: How do I want my transfer delivered?
●
Delivery of payment is based on completion of the withdrawal process, which includes receipt of a complete request in good order and additional/
required information from my employer.
●
I must select a delivery option from the choices provided. If I do not make any selection, all transactions will be sent by regular mail.
●
Below is a description of each delivery option.
Check by USPS Regular Mail
●
Estimated delivery time is 7-10 business days
●
No additional charge
Check by Express Delivery
●
Estimated delivery time is 1-2 business days
●
A non-refundable charge of up to $25.00 will be deducted, in addition to any withdrawal fees, for each transaction, which will be added to the purchase
of service credit transfer amount requested.
●
Available for delivery, Monday-Friday, with no signature required upon delivery
●
If the address is a P.O. Box, the check will be sent by USPS Priority Mail and estimated delivery time is 2-3 business days.
●
Delivery is not guaranteed to all areas
Section E: Signatures and Consent
●
Handwritten signatures are required on this form. Electronic signatures will not be accepted and will result in a significant delay.
My Consent
●
My signature and the date are required.
●
I attest to receiving, reading, understanding and agreeing to all provisions of this Transfer Form and the Purchase of Service Credits Guide.
●
It is entirely my responsibility to ensure that this election conforms with all applicable provisions of the Internal Revenue Code (the "Code") and that
the Plan into which I am transferring money over will accept the dollars.
●
Once a payment has been processed, it cannot be changed.
●
In the event that any section of this form is incomplete or inaccurate, Service Provider may not process the transaction requested on this form and
may require a new form or that I provide additional or proper information before the transaction can be processed.
My Authorized Plan Administrator Signature
●
My Authorized Plan Administrator's signature is required in order for this Transfer Form to be processed.
STD FPRCRD ][05/13/24)( 524954-01 WITHDRAWAL
NO_GRPG 52478/][GU37)(/][DIXK
DOC ID: 25212233)(
Page 3 of 4
Purchase of Service Credits Transfer Guide - Governmental 457(b)
The Purchase of Service Credits Transfer Request
Before completing the form, please note the following information:
●
All pages of the Purchase of Service Credits Transfer Request form ("Transfer Form") must be returned excluding the Purchase of Service Credits
Transfer Guide.
●
Neither this Guide nor this Transfer Form are intended to provide tax or legal advice. In the preparation of this Transfer Form, and where I deem
appropriate, I will seek a consultation with my accountant and/or tax advisor.
●
Empower ("Service Provider") cannot release the funds until my employer confirms that I am entitled to take a transfer from the Plan.
●
If I would like a different withdrawal option other than Purchase of Service Credits, I need to complete either the In-Service Withdrawal
form, if I am still employed with the Employer/Company sponsoring this Plan or the Separation from Employment Withdrawal form, if I am
no longer working for the Employer/Company sponsoring this Plan.
●
If I have more than one account or plan number, I must complete a separate Transfer Form for each account or plan number.
Changes to My Request
●
Any changes to this Transfer Form must be crossed out and initialed. If I do not initial all changes, this Transfer Form may be returned to me for
verification.
Incomplete or Inaccurate Information
●
In the event that any section of this Transfer Form is incomplete or inaccurate, Service Provider may not be able to process the transaction requested
on this Transfer Form. I may be required to complete a new form or provide additional or proper information before the transaction will be processed.
Section A: What is my personal information?
●
All information in this section must be completed.
●
The name provided MUST match the name on file with Service Provider.
●
Personal information will be kept confidential.
●
If I am a non-resident alien, I must attach, to each withdrawal request, a current version of the IRS Form W-8BEN with an original signature and this
must be sent by mail or express delivery. Service Provider cannot accept a fax of this form.
●
I may call 1-800-TAX-FORM (829-3676) or visit irs.gov to obtain a current version of an IRS Form W-8BEN.
Section B: How much am I requesting?
●
I must enter the amount that I would like transferred, up to and including the amount shown on the Notification of Eligibility/Acceptance letter.
●
If my Plan charges any distribution fees or I choose an optional delivery method that has a fee, these will be added to the amount approved for a
transfer, thereby increasing the amount disbursed from my account by the amount of these fees.
Section C: To whom do I want my transfer payable and where should it be sent?
●
It is my responsibility to make sure that the Name/Trustee of the Defined Benefit Plan information provided is accurate. Service Provider is not
responsible for misdirected payments due to an incorrect address.
Section D: How do I want my transfer delivered?
●
Delivery of payment is based on completion of the withdrawal process, which includes receipt of a complete request in good order and additional/
required information from my employer.
●
I must select a delivery option from the choices provided. If I do not make any selection, all transactions will be sent by regular mail.
●
Below is a description of each delivery option.
Check by USPS Regular Mail
●
Estimated delivery time is 7-10 business days
●
No additional charge
Check by Express Delivery
●
Estimated delivery time is 1-2 business days
●
A non-refundable charge of up to $25.00 will be deducted, in addition to any withdrawal fees, for each transaction, which will be added to the purchase
of service credit transfer amount requested.
●
Available for delivery, Monday-Friday, with no signature required upon delivery
●
If the address is a P.O. Box, the check will be sent by USPS Priority Mail and estimated delivery time is 2-3 business days.
●
Delivery is not guaranteed to all areas
Section E: Signatures and Consent
●
Handwritten signatures are required on this form. Electronic signatures will not be accepted and will result in a significant delay.
My Consent
●
My signature and the date are required.
●
I attest to receiving, reading, understanding and agreeing to all provisions of this Transfer Form and the Purchase of Service Credits Guide.
●
It is entirely my responsibility to ensure that this election conforms with all applicable provisions of the Internal Revenue Code (the "Code") and that
the Plan into which I am transferring money over will accept the dollars.
●
Once a payment has been processed, it cannot be changed.
●
In the event that any section of this form is incomplete or inaccurate, Service Provider may not process the transaction requested on this form and
may require a new form or that I provide additional or proper information before the transaction can be processed.
My Authorized Plan Administrator Signature
●
My Authorized Plan Administrator's signature is required in order for this Transfer Form to be processed.
It is my responsibility to indicate the correct Name/Trustee of the Dened Benet Plan on the form.
524954-01
Last Name First Name M.I. Social Security Number Number
STD FPRCRD ][05/13/24)( 524954-01 WITHDRAWAL
NO_GRPG 52478/][GU37)(/][DIXK
DOC ID: 25212233)(
Page 2 of 4
D
How do I want my transfer delivered? (Continue to the next section after completing.)
Select One - Delivery of payment is based on completion of the withdrawal process, which includes
receipt of a complete request in good order and additional/required information from my employer.
Check by USPS Regular Mail
●
Estimated delivery time is 7-10 business days
●
No additional charge
Check by Express Delivery
●
Estimated delivery time is 1-2 business days
●
A non-refundable charge of up to $25.00 will be deducted, in addition to any withdrawal fees, for each transaction, which will be added to
the purchase of service credit transfer amount requested.
●
Available for delivery, Monday - Friday, with no signature required upon delivery
●
If address is a P.O. Box, check will be sent by USPS Priority Mail and estimated delivery time is 2-3 business days.
E
Signatures and Consent (Signatures must be on the lines provided.) (After receiving ALL required signatures, continue to the next section.)
My Consent (Please sign on the ‘My Signature’ line below.)
I acknowledge that I have read, understand and agree to all pages of this Purchase of Service Credits Transfer Request and the Purchase of
Service Credits Transfer Guide and affirm that all information that I have provided is true and correct. Pursuant to the enclosed Notification of
Eligibility/Acceptance letter from my employer’s governmental defined benefit plan, I hereby authorize the transfer of deferred (pre-tax) funds in the
amount indicated above from my Governmental 457(b) Plan for the purpose of purchasing retirement service credits. I understand the following:
●
Funds may impose redemption fees on certain transfers, redemptions or exchanges if assets are held less than the period stated in the fund's
prospectus or other disclosure documents. I will refer to the fund's prospectus and/or disclosure documents for more information.
●
Under penalty of perjury, I certify that the U.S. Social Security number or U.S. Taxpayer Identification number I have provided in Section A is
correct. I am a U.S. person if I marked the U.S. Citizen or U.S. Resident Alien box in Section A of this form.
●
Additional authentication may be necessary before my withdrawal is processed and/or payment released.
●
My withdrawal may be subject to fees and/or loss of interest based upon my investment options, my length of time in the Plan and
other possible considerations. If I have not been advised of the fees and risks associated with my withdrawal, I may contact Service
Provider for a withdrawal quote at 1-866-657-3327.
Any person who presents a false or fraudulent claim is subject to criminal and civil penalties.
My Signature Date (Required)
A handwritten signature is required on this form. An electronic signature will not be accepted and will result in a significant delay.
My Authorized Plan Administrator Signature (Please sign on the 'Authorized Plan Administrator Signature' line below.)
I certify that this request is in compliance with applicable Plan provisions and federal law and that the participant has received from the Plan any
notices required by law. I approve this transfer as it is presented on this form.
I represent that I am an authorized signer on behalf of the above-named Plan and have an authority to instruct Service Provider to process this form.
Authorized
Plan Administrator Signature Date (Required)
A handwritten signature is required on this form. An electronic signature will not be accepted and will result in a significant delay.
Print Full Name
F
Where should I send this form?
After all signatures have been obtained, this form and a copy of the Notification of Eligibility/Acceptance letter can be
Uploaded Electronically:
Login to account at
empower.com/njplans
Click on Upload Documents to submit
OR Sent Regular Mail to:
Empower
PO Box 56025
Boston, MA 02205-6025
OR Sent Express Mail to:
Empower
8515 E. Orchard Road
Greenwood Village, CO 80111
We will not accept hand delivered forms at Express Mail addresses.
The group variable annuity insurance products are issued through Empower Annuity Insurance Company, Hartford, CT and distributed through Empower
Financial Services, Inc., (EFSI). Both are Empower companies and each organization is solely responsible for its financial condition and contractual
obligations. Annuity contracts contain exclusions, limitations, reductions of benefits and terms for keeping them in force. The annuity or certain of its
investment options or features may not be available in all states. Policy forms currently available include DC- 08-TGWB-2011, ALC-408-TGWB-2011-NR,
ALC-408-TGWB-2011-ROTH, IND-IFX-TGWB-2013-NR, IND-IFX-TGWB-2013-ROTH or state variation thereof.
You could lose money by investing in money market investments. Although they seek to preserve the value of your investment at $1 or $10.00 per share
(see the prospectus), there is no guarantee they will. An investment in a money market investment is not insured or guaranteed by the Federal Deposit
Insurance Corporation or any other government agency. The money market investment’s sponsor has no legal obligation to provide financial support to
the portfolio, and you should not expect that the sponsor will provide financial support to the portfolio at any time. The yield quotation more closely reflects
the current earnings of the portfolio than the total return quotation.
DAES/MANUAL/SR 13644521
Page 4 of 5
STD FPRCRD ][05/13/24)( 524954-01 WITHDRAWAL
NO_GRPG 52478/][GU37)(/][DIXK
DOC ID: 25212233)(
Page 3 of 4
Purchase of Service Credits Transfer Guide - Governmental 457(b)
The Purchase of Service Credits Transfer Request
Before completing the form, please note the following information:
●
All pages of the Purchase of Service Credits Transfer Request form ("Transfer Form") must be returned excluding the Purchase of Service Credits
Transfer Guide.
●
Neither this Guide nor this Transfer Form are intended to provide tax or legal advice. In the preparation of this Transfer Form, and where I deem
appropriate, I will seek a consultation with my accountant and/or tax advisor.
●
Empower ("Service Provider") cannot release the funds until my employer confirms that I am entitled to take a transfer from the Plan.
●
If I would like a different withdrawal option other than Purchase of Service Credits, I need to complete either the In-Service Withdrawal
form, if I am still employed with the Employer/Company sponsoring this Plan or the Separation from Employment Withdrawal form, if I am
no longer working for the Employer/Company sponsoring this Plan.
●
If I have more than one account or plan number, I must complete a separate Transfer Form for each account or plan number.
Changes to My Request
●
Any changes to this Transfer Form must be crossed out and initialed. If I do not initial all changes, this Transfer Form may be returned to me for
verification.
Incomplete or Inaccurate Information
●
In the event that any section of this Transfer Form is incomplete or inaccurate, Service Provider may not be able to process the transaction requested
on this Transfer Form. I may be required to complete a new form or provide additional or proper information before the transaction will be processed.
Section A: What is my personal information?
●
All information in this section must be completed.
●
The name provided MUST match the name on file with Service Provider.
●
Personal information will be kept confidential.
●
If I am a non-resident alien, I must attach, to each withdrawal request, a current version of the IRS Form W-8BEN with an original signature and this
must be sent by mail or express delivery. Service Provider cannot accept a fax of this form.
●
I may call 1-800-TAX-FORM (829-3676) or visit irs.gov to obtain a current version of an IRS Form W-8BEN.
Section B: How much am I requesting?
●
I must enter the amount that I would like transferred, up to and including the amount shown on the Notification of Eligibility/Acceptance letter.
●
If my Plan charges any distribution fees or I choose an optional delivery method that has a fee, these will be added to the amount approved for a
transfer, thereby increasing the amount disbursed from my account by the amount of these fees.
Section C: To whom do I want my transfer payable and where should it be sent?
●
It is my responsibility to make sure that the Name/Trustee of the Defined Benefit Plan information provided is accurate. Service Provider is not
responsible for misdirected payments due to an incorrect address.
Section D: How do I want my transfer delivered?
●
Delivery of payment is based on completion of the withdrawal process, which includes receipt of a complete request in good order and additional/
required information from my employer.
●
I must select a delivery option from the choices provided. If I do not make any selection, all transactions will be sent by regular mail.
●
Below is a description of each delivery option.
Check by USPS Regular Mail
●
Estimated delivery time is 7-10 business days
●
No additional charge
Check by Express Delivery
●
Estimated delivery time is 1-2 business days
●
A non-refundable charge of up to $25.00 will be deducted, in addition to any withdrawal fees, for each transaction, which will be added to the purchase
of service credit transfer amount requested.
●
Available for delivery, Monday-Friday, with no signature required upon delivery
●
If the address is a P.O. Box, the check will be sent by USPS Priority Mail and estimated delivery time is 2-3 business days.
●
Delivery is not guaranteed to all areas
Section E: Signatures and Consent
●
Handwritten signatures are required on this form. Electronic signatures will not be accepted and will result in a significant delay.
My Consent
●
My signature and the date are required.
●
I attest to receiving, reading, understanding and agreeing to all provisions of this Transfer Form and the Purchase of Service Credits Guide.
●
It is entirely my responsibility to ensure that this election conforms with all applicable provisions of the Internal Revenue Code (the "Code") and that
the Plan into which I am transferring money over will accept the dollars.
●
Once a payment has been processed, it cannot be changed.
●
In the event that any section of this form is incomplete or inaccurate, Service Provider may not process the transaction requested on this form and
may require a new form or that I provide additional or proper information before the transaction can be processed.
My Authorized Plan Administrator Signature
●
My Authorized Plan Administrator's signature is required in order for this Transfer Form to be processed.
STD FPRCRD ][05/13/24)( 524954-01 WITHDRAWAL
NO_GRPG 52478/][GU37)(/][DIXK
DOC ID: 25212233)(
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Purchase of Service Credits Transfer Guide - Governmental 457(b)
The Purchase of Service Credits Transfer Request
Before completing the form, please note the following information:
●
All pages of the Purchase of Service Credits Transfer Request form ("Transfer Form") must be returned excluding the Purchase of Service Credits
Transfer Guide.
●
Neither this Guide nor this Transfer Form are intended to provide tax or legal advice. In the preparation of this Transfer Form, and where I deem
appropriate, I will seek a consultation with my accountant and/or tax advisor.
●
Empower ("Service Provider") cannot release the funds until my employer confirms that I am entitled to take a transfer from the Plan.
●
If I would like a different withdrawal option other than Purchase of Service Credits, I need to complete either the In-Service Withdrawal
form, if I am still employed with the Employer/Company sponsoring this Plan or the Separation from Employment Withdrawal form, if I am
no longer working for the Employer/Company sponsoring this Plan.
●
If I have more than one account or plan number, I must complete a separate Transfer Form for each account or plan number.
Changes to My Request
●
Any changes to this Transfer Form must be crossed out and initialed. If I do not initial all changes, this Transfer Form may be returned to me for
verification.
Incomplete or Inaccurate Information
●
In the event that any section of this Transfer Form is incomplete or inaccurate, Service Provider may not be able to process the transaction requested
on this Transfer Form. I may be required to complete a new form or provide additional or proper information before the transaction will be processed.
Section A: What is my personal information?
●
All information in this section must be completed.
●
The name provided MUST match the name on file with Service Provider.
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Personal information will be kept confidential.
●
If I am a non-resident alien, I must attach, to each withdrawal request, a current version of the IRS Form W-8BEN with an original signature and this
must be sent by mail or express delivery. Service Provider cannot accept a fax of this form.
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I may call 1-800-TAX-FORM (829-3676) or visit irs.gov to obtain a current version of an IRS Form W-8BEN.
Section B: How much am I requesting?
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I must enter the amount that I would like transferred, up to and including the amount shown on the Notification of Eligibility/Acceptance letter.
●
If my Plan charges any distribution fees or I choose an optional delivery method that has a fee, these will be added to the amount approved for a
transfer, thereby increasing the amount disbursed from my account by the amount of these fees.
Section C: To whom do I want my transfer payable and where should it be sent?
●
It is my responsibility to make sure that the Name/Trustee of the Defined Benefit Plan information provided is accurate. Service Provider is not
responsible for misdirected payments due to an incorrect address.
Section D: How do I want my transfer delivered?
●
Delivery of payment is based on completion of the withdrawal process, which includes receipt of a complete request in good order and additional/
required information from my employer.
●
I must select a delivery option from the choices provided. If I do not make any selection, all transactions will be sent by regular mail.
●
Below is a description of each delivery option.
Check by USPS Regular Mail
●
Estimated delivery time is 7-10 business days
●
No additional charge
Check by Express Delivery
●
Estimated delivery time is 1-2 business days
●
A non-refundable charge of up to $25.00 will be deducted, in addition to any withdrawal fees, for each transaction, which will be added to the purchase
of service credit transfer amount requested.
●
Available for delivery, Monday-Friday, with no signature required upon delivery
●
If the address is a P.O. Box, the check will be sent by USPS Priority Mail and estimated delivery time is 2-3 business days.
●
Delivery is not guaranteed to all areas
Section E: Signatures and Consent
●
Handwritten signatures are required on this form. Electronic signatures will not be accepted and will result in a significant delay.
My Consent
●
My signature and the date are required.
●
I attest to receiving, reading, understanding and agreeing to all provisions of this Transfer Form and the Purchase of Service Credits Guide.
●
It is entirely my responsibility to ensure that this election conforms with all applicable provisions of the Internal Revenue Code (the "Code") and that
the Plan into which I am transferring money over will accept the dollars.
●
Once a payment has been processed, it cannot be changed.
●
In the event that any section of this form is incomplete or inaccurate, Service Provider may not process the transaction requested on this form and
may require a new form or that I provide additional or proper information before the transaction can be processed.
My Authorized Plan Administrator Signature
●
My Authorized Plan Administrator's signature is required in order for this Transfer Form to be processed.
It is my responsibility to indicate the correct Name/Trustee of the Dened Benet Plan on the form.
524954-01
Last Name First Name M.I. Social Security Number Number
STD FPRCRD ][05/13/24)( 524954-01 WITHDRAWAL
NO_GRPG 52478/][GU37)(/][DIXK
DOC ID: 25212233)(
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D
How do I want my transfer delivered? (Continue to the next section after completing.)
Select One - Delivery of payment is based on completion of the withdrawal process, which includes
receipt of a complete request in good order and additional/required information from my employer.
Check by USPS Regular Mail
●
Estimated delivery time is 7-10 business days
●
No additional charge
Check by Express Delivery
●
Estimated delivery time is 1-2 business days
●
A non-refundable charge of up to $25.00 will be deducted, in addition to any withdrawal fees, for each transaction, which will be added to
the purchase of service credit transfer amount requested.
●
Available for delivery, Monday - Friday, with no signature required upon delivery
●
If address is a P.O. Box, check will be sent by USPS Priority Mail and estimated delivery time is 2-3 business days.
E
Signatures and Consent (Signatures must be on the lines provided.) (After receiving ALL required signatures, continue to the next section.)
My Consent (Please sign on the ‘My Signature’ line below.)
I acknowledge that I have read, understand and agree to all pages of this Purchase of Service Credits Transfer Request and the Purchase of
Service Credits Transfer Guide and affirm that all information that I have provided is true and correct. Pursuant to the enclosed Notification of
Eligibility/Acceptance letter from my employer’s governmental defined benefit plan, I hereby authorize the transfer of deferred (pre-tax) funds in the
amount indicated above from my Governmental 457(b) Plan for the purpose of purchasing retirement service credits. I understand the following:
●
Funds may impose redemption fees on certain transfers, redemptions or exchanges if assets are held less than the period stated in the fund's
prospectus or other disclosure documents. I will refer to the fund's prospectus and/or disclosure documents for more information.
●
Under penalty of perjury, I certify that the U.S. Social Security number or U.S. Taxpayer Identification number I have provided in Section A is
correct. I am a U.S. person if I marked the U.S. Citizen or U.S. Resident Alien box in Section A of this form.
●
Additional authentication may be necessary before my withdrawal is processed and/or payment released.
●
My withdrawal may be subject to fees and/or loss of interest based upon my investment options, my length of time in the Plan and
other possible considerations. If I have not been advised of the fees and risks associated with my withdrawal, I may contact Service
Provider for a withdrawal quote at 1-866-657-3327.
Any person who presents a false or fraudulent claim is subject to criminal and civil penalties.
My Signature Date (Required)
A handwritten signature is required on this form. An electronic signature will not be accepted and will result in a significant delay.
My Authorized Plan Administrator Signature (Please sign on the 'Authorized Plan Administrator Signature' line below.)
I certify that this request is in compliance with applicable Plan provisions and federal law and that the participant has received from the Plan any
notices required by law. I approve this transfer as it is presented on this form.
I represent that I am an authorized signer on behalf of the above-named Plan and have an authority to instruct Service Provider to process this form.
Authorized
Plan Administrator Signature Date (Required)
A handwritten signature is required on this form. An electronic signature will not be accepted and will result in a significant delay.
Print Full Name
F
Where should I send this form?
After all signatures have been obtained, this form and a copy of the Notification of Eligibility/Acceptance letter can be
Uploaded Electronically:
Login to account at
empower.com/njplans
Click on Upload Documents to submit
OR Sent Regular Mail to:
Empower
PO Box 56025
Boston, MA 02205-6025
OR Sent Express Mail to:
Empower
8515 E. Orchard Road
Greenwood Village, CO 80111
We will not accept hand delivered forms at Express Mail addresses.
The group variable annuity insurance products are issued through Empower Annuity Insurance Company, Hartford, CT and distributed through Empower
Financial Services, Inc., (EFSI). Both are Empower companies and each organization is solely responsible for its financial condition and contractual
obligations. Annuity contracts contain exclusions, limitations, reductions of benefits and terms for keeping them in force. The annuity or certain of its
investment options or features may not be available in all states. Policy forms currently available include DC- 08-TGWB-2011, ALC-408-TGWB-2011-NR,
ALC-408-TGWB-2011-ROTH, IND-IFX-TGWB-2013-NR, IND-IFX-TGWB-2013-ROTH or state variation thereof.
You could lose money by investing in money market investments. Although they seek to preserve the value of your investment at $1 or $10.00 per share
(see the prospectus), there is no guarantee they will. An investment in a money market investment is not insured or guaranteed by the Federal Deposit
Insurance Corporation or any other government agency. The money market investment’s sponsor has no legal obligation to provide financial support to
the portfolio, and you should not expect that the sponsor will provide financial support to the portfolio at any time. The yield quotation more closely reflects
the current earnings of the portfolio than the total return quotation.
DAES/MANUAL/SR 13644521
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STD FPRCRD ][05/13/24)( 524954-01 WITHDRAWAL
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DOC ID: 25212233)(
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Section F: Where should I send this form?
●
Once I have completed this Transfer Form, including obtaining all signatures, I must forward it and the Notification of Eligibility/Acceptance letter
according to the instructions listed in this section.
●
If I have elected to upload this Transfer Form to Service Provider, I need to allow 2-4 hours for receipt before I check on the status.
●
We will not accept hand delivered forms at Express Mail addresses.
Important Note
●
Although every effort is made to keep the information in this Guide current, it is subject to change without notice. Federal, state, and local tax laws
may be revised, and new Plan provisions may be adopted by the Plan. For the most up to date version of this Guide, please visit the website at
empower.com/njplans or call Client Service at 1-866-657-3327.
●
Access to the Voice Response System or the website may be limited or unavailable during periods of peak demand, market volatility, systems
upgrades, maintenance or for other reasons.
●
For more information about available investment options, including fees and expenses, I may obtain applicable prospectuses and/or disclosure
documents regarding Plan investments and fees available from my Plan administrator and/or Plan Service representative. Read them carefully before
investing.
STD FPRCRD ][05/13/24)( 524954-01 WITHDRAWAL
NO_GRPG 52478/][GU37)(/][DIXK
DOC ID: 25212233)(
Page 4 of 4
Section F: Where should I send this form?
●
Once I have completed this Transfer Form, including obtaining all signatures, I must forward it and the Notification of Eligibility/Acceptance letter
according to the instructions listed in this section.
●
If I have elected to upload this Transfer Form to Service Provider, I need to allow 2-4 hours for receipt before I check on the status.
●
We will not accept hand delivered forms at Express Mail addresses.
Important Note
●
Although every effort is made to keep the information in this Guide current, it is subject to change without notice. Federal, state, and local tax laws
may be revised, and new Plan provisions may be adopted by the Plan. For the most up to date version of this Guide, please visit the website at
empower.com/njplans or call Client Service at 1-866-657-3327.
●
Access to the Voice Response System or the website may be limited or unavailable during periods of peak demand, market volatility, systems
upgrades, maintenance or for other reasons.
●
For more information about available investment options, including fees and expenses, I may obtain applicable prospectuses and/or disclosure
documents regarding Plan investments and fees available from my Plan administrator and/or Plan Service representative. Read them carefully before
investing.
STD FPRCRD ][07/08/24)( 524954-01 WITHDRAWAL
NO_GRPG 52478/][GU37)(/][DAES
DOC ID: 31027669)(
Page 5 of 5
Section F: Where should I send this form?
●
Once I have completed this Transfer Form, including obtaining all signatures, I must forward it and the Notification of Eligibility/Acceptance letter
according to the instructions listed in this section.
●
We will not accept hand delivered forms at Express Mail addresses.
Important Note
●
Although every effort is made to keep the information in this Guide current, it is subject to change without notice. Federal, state, and local tax laws
may be revised, and new Plan provisions may be adopted by the Plan. For the most up to date version of this Guide, please visit the website at
empower.com/njplans or call Client Service at 1-866-657-3327.
●
Access to the Voice Response System or the website may be limited or unavailable during periods of peak demand, market volatility, systems
upgrades, maintenance or for other reasons.
●
For more information about available investment options, including fees and expenses, I may obtain applicable prospectuses and/or disclosure
documents regarding Plan investments and fees available from my Plan administrator and/or Plan Service representative. Read them carefully before
investing.
