State of Georgia 401(k) Rollover Contribution Form Please ... - Intranet

State of Georgia
401(k) Rollover Contribution Form
Please print or type the following information
Name
Address
Date of Birth
Social Security Number
City State, Zip Work Location
Phone Number
Complete this Rollover Contribution Form and:
• Attach your Tax Distribution Statement from your former plan
• Attach your rollover check payable to CitiStreet, FBO (your name)
After-tax assets may NOT be rolled into Peach State Reserves.
I elect to make a rollover contribution to the State of Georgia 401(k) Plan in the amount of $ ____________________________.
_____ Direct rollover from a qualified 401(a), 401(k) or 403(b) plan (circle applicable plan type)
_____ Direct rollover from a traditional IRA (educational and ROTH IRAs may NOT be rolled over)
_____ Direct rollover from a governmental 457(b) plan
The contribution must be invested in multiples of 1% in one or more of the following funds. The total must equal 100%.
Stable Value Fund (Fund 20) _______% Large Cap Value Stock Index Fund (Fund 30) _______%
Active Core Bond Fund (Fund 21) _______% Large Cap Core Stock Index Fund (Fund 34) _______%
Lifecycle Income Fund (Fund 22) _______% Large Cap Growth Stock Index Fund (Fund 33) _______%
Lifecycle 2010 Fund (Fund 23) _______% Mid Cap Core Stock Index Fund (Fund 31) _______%
Lifecycle 2020 Fund (Fund 24) _______% Small Mid Value Stock Fund (Fund 29) _______%
Lifecycle 2030 Fund (Fund 25) _______% Small Mid Growth Stock Fund (Fund 35) _______%
Lifecycle 2040 Fund (Fund 26) _______% Small Cap Core Stock Index Fund (Fund 32) _______%
Active Large Cap Value Index Fund (Fund 28) _______% Active International Stock Fund (Fund 36) _______%
Active Large Cap Growth Stock Fund (Fund 27) _______% Active Real Estate Securities Fund (Fund 37) _______%
I certify that all of the assets to be invested as specified above are qualified moneys and are eligible to rollover to the State of Georgia
401(k) Plan. I understand that the Plan will not be held responsible for any tax penalties that may occur for an incomplete submission.
I certify that all funds being rolled into the State of Georgia 401(k) Plan were deducted on a pre-tax basis. If you are not currently
participating in the State of Georgia 401(k) Plan, you need to log on to the Plan Website at http://myGApsr.csplans.com to make a
beneficiary designation. If you are married and would like to name someone other than your spouse as primary beneficiary, you must
complete a Beneficiary Designation Form – Spousal Waiver Form. To obtain a form, you may call the Peach State Reserves Plan
Information line at 1-866-694-2777 or print the form on the Plan Website: http://myGApsr.csplans.com
Participant’s Signature ____________________________________________________________Date ________________________
Note: This allocation will not affect any current or future investment elections. If you wish to make changes to current or future
investment elections, you will need to call 1-866-MY-GA-PSR or 1-866-694-2777, or visit the website: http://myGApsr.csplans.com

Participant Acknowledgements
Sign and date in the space provided on the form. In addition to the specific instructions and conditions set forth elsewhere in this Agreement, your
signature shall constitute affirmation of the following general conditions, acknowledgments, and authorizations:
1. I hereby agree to the terms and conditions of participation in this Plan as set forth in Federal law, Regulations, and the official Plan as adopted
and amended by the ERS Board; in any conflict between this Form and the terms of the Plan, I acknowledge that the terms of the Plan shall
prevail.
2. I understand that only certain types of distributions are eligible for rollover into the State of Georgia Deferred Compensation Section 401(k)
Plan and that it is solely my responsibility to ensure such eligibility, including the condition of pre-tax assets only (both contributions and
earnings). By signing below, I affirm that the funds I am rolling are, in fact, eligible for such treatment, and that no after-tax assets are a part of
this rollover.
3. I authorize these funds to be transferred into the State of Georgia Employees’ Deferred Compensation Section 401(k) Plan and to be invested
according to the information specified the Investment Option Information section. If the investment option information is missing or incomplete,
I authorize CitiStreet to allocate the direct rollover assets in the same manner as my ongoing contributions, if I already have an account
established, or if no current account is established with investment allocations, to allocate the rollover assets to the appropriate aged based
default fund. I understand that I must call the Peach State Reserves Plan Information Line at 1-866-694-2777 or access my account via the
Plan Website at http://myGApsr.csplans.com in order to make changes or transfer monies once invested into the Plan.
4. I understand that my Custodian/Provider of the Plan from which I wish to rollover assets may require that I furnish additional information
and/or application before processing the transaction requested on this form, and CitiStreet is NOT responsible for determining the status of any
transaction that I have requested. It is entirely my responsibility to provide the Custodian/Provider of the Plan from which I wish to rollover
assets with any information that they may require, and/or to notify CitiStreet of any information that the Custodian/Provider may wish to obtain
in order to effect the transaction.
5. Withdrawal Restrictions - I understand that the availability to withdraw assets from the Plan prior to permanent separation of service with the
State of Georgia is extremely limited, and subject to Federal law, Regulations and the official Plan as adopted and amended by the ERS Board,
and that loans are not available.
6. I understand that at the time I become entitled to withdraw my Plan assets, I can only be paid the then-current market value of those
investments, and that any value invested in stocks, bonds, or other market-priced securities may increase or decrease as such market values go
up or down.
7. I understand that it is my responsibility to notify Plan staff of any apparent errors in postings to my Account within sixty (60) days following
receipt of the quarterly Account statement reflecting such apparent errors, and that correction of any de minimis errors having negligible impact
shall be at the discretion of the Plan. After these 60 days, account information shall be deemed accurate and acceptable to me. If I notify Georgia
Deferred Compensation of an error after these 60 days, the correction will only be processed from the date of notification forward and not on a
retroactive basis.
8. I understand and acknowledge that the ERS, notwithstanding any requested investment designation by me, has the authority to eliminate any
current Plan Investment Option, and to transfer any value of my Account credited to such Option (or subsequent contributions allocated to such
Option) into any Option(s) selected by the Board then remaining and available, unless I specify the redirection of my account within the time
allotted by the Board.
9. I understand that participation in the Deferred Compensation 401(k) Plan is an optional benefit offered by the State of Georgia. In return for
this benefit, I and my heirs, assignees and successors shall hold harmless the ERS Board and the Employer, including any and all of their
employees, officials, agents, assignees and successors, from any and all liability for all acts performed in good faith.
Mailing Address for Form: Overnight Address for Form: Fax number for Form:
(Preferred method of receipt)
CitiStreet CitiStreet CitiStreet
State of Georgia Plan Administration State of Georgia Plan Administration Attn. State of Georgia
P.O. Box 5166 1 Heritage Dr 1(800) 596-5715
Boston, MA 02206-5166 Quincy, MA 02191
Note: Please make checks payable to CitiStreet, FBO (your name)