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457 plan co-provider Transfer
To ICMA-RC Form
If your employer’s 457 plan has multiple providers, you can use this form to transfer assets from one of the co-providers to ICMA-RC’s 457 plan.
Do not use this packet to transfer assets from a previous employer’s 457 plan to your current employer’s 457 plan. Contact ICMA-RC and request
the Direct Rollover/Transfer to ICMA-RC Packet.
457 PLAN CO-PROVIDER TRANSFER TO ICMA-RC FORM INSTRUCTIONS
Thank you for your decision to transfer your 457 plan assets to the ICMARC 457 plan. If you have any questions, please contact Investor Services
toll-free at 800-669-7400.
1.If your current employer’s 457 plan has multiple providers, you can
use the forms in this packet to transfer assets from one of the coproviders to ICMA-RC’s 457 plan.
2.Contact the co-provider that currently holds your assets, and confirm
that they will accept ICMA-RC’s paperwork.
3.Return the completed form to ICMA-RC (in the envelope provided).
Section 1: Personal Information - Provide all of the requested
personal information. If you have not yet enrolled in the ICMA-RC 457
plan with your current employer, please contact ICMA-RC at 800-6697400 and request the 457 Deferred Compensation Plan Employee
Enrollment Form. The form is also available online at www.icmarc.org/
forms.
Section 2: Transfer To - Indicate your ICMA-RC 457 plan number
and employer plan name.
Section 3a: Transfer From - Provide all of the requested account
information. Be sure to include your account number.
Section 3b: Transfer Amount - Indicate whether you wish to transfer
the total value (100%) of your account or a portion of your account. If
you are requesting a partial transfer, specify the dollar amounts and
funds you wish to transfer.
Section 3c: Source of Assets - Box 1. If all assets being transferred
from the co-provider are 457 plan contributions (and associated
earnings) made through your current employer, check box 1.
Box 2*. Otherwise, check box 2 to indicate that the transfer contains
rollover assets from a previous employer’s plan. Contact the plan
provider to obtain the following information:
1.Dollar amount of 457 plan contributions and earnings
2.Dollar amount of 457 rollover assets (from a previous employer)
3.Dollar amount of rollover assets from qualified plans (401(a),
401(k), 403(b), IRA assets)
*IMPORTANT NOTE: If you check box 2 and do not provide additional
details, the assets may be tracked improperly by ICMA-RC, and could
result in tax consequences to you. Rollover assets must be tracked
separately by ICMA-RC to ensure proper tax reporting.
Section 4: Investment Allocation - Please read this section
carefully. It contains detailed information on how the assets you transfer
to your ICMA-RC account will be invested.
Section 5: Participant Signature - By signing this form, you
are attesting to the following: I have received and read the current
VantageTrust’s Making Sound Investment Decisions: A Retirement
Investment Guide and the applicable prospectus for my investments.
As required by law and under penalty of perjury, I certify that the Social
Security Number (taxpayer identification number) I provided for myself is
correct.
I hereby agree to indemnify the custodian ICMA-RC (its agents, affiliates,
successors and employees) and J.P. Morgan Chase Bank, N.A., ICMA-RC
Services and their affiliates from any and all liability resulting from my
failure to meet any IRS requirements.
Section 6: Employer Authorization - By signing this section, your
current employer is confirming that you are eligible to transfer to the
ICMA-RC 457 plan shown in Section 2.
Section 7: Signature Guarantee - Some plan providers require
a signature guarantee on the transfer request form (ICMA-RC does not).
Please check with the co-provider to see if they require a signature
guarantee, as the lack of a required signature guarantee may delay
the processing of your transfer request. Signature guarantees can be
obtained at most local banks.
Section 8: ICMA-RC/ICMA-RC Services Authorization - This
section verifies to the transferring trustee or custodian that ICMA-RC
maintains an eligible 457 plan which is eligible to receive transfers.
Section 9: Document Mailing and Check/Wire Instructions for
Former Trustee/Custodian
Mail all forms to: ICMA-RC
Attn: Workflow Management Team
PO Box 96220
Washington, DC 20090-6220
OR fax to: 202-682-6492
Attn: Workflow Management Team
Mail Checks to:
Vantagepoint Transfer Agents/457
c/o M&T Bank
P.O. Box 64553
Baltimore, MD 21264-4553
Send Wire transfers to:
M&T Bank
ABA# 022000046
VANTAGEPOINT TRANSFER AGENTS-457
Account# 42538001
Important Note: If you have not yet enrolled in the ICMA-RC 457
plan with your current employer, please contact ICMA-RC at 800-6697400 and request the 457 Deferred Compensation Plan Employee Enrollment Form (available online at www.icmarc.org). You should complete
the enrollment process prior to requesting the co-provider transfer.
FRM000-100-201012-917
457 CO-PROVIDER TRANSFER TO ICMA-RC FORM - Page 1 of 3
•Use this form to request a transfer from your current employer’s 457 plan with a co-provider. Do not use this form for a rollover request.
•If you have not yet enrolled in the ICMA-RC 457 plan with your current employer, you must also commplete the 457 Deferred Compensation Plan Employee Enrollment Form.
1
Personal
Information
Full Name of Participant
___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Last
First
Social Security Number (for tax reporting purposes)
Date of Birth
___ ___ ___ - ___ ___ - ___ ___ ___ ___
___ ___ / ___ ___ / ___ ___ ___ ___
Mailing Address/Street
Month
Day
Daytime Phone Number
Year
( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___
Area Code
Marital Status
___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
2
Transfer To
3a
Transfer
From
(must be
completed
for all
transfers)
M.I.
City
State
___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
___ ___
Zip Code


Married
Single
___ ___ ___ ___ ___ ___
ICMA-RC 457 Plan Account Number: 30______ ______ ______ ______
Employer Plan Name:__________________________________________________________________________________________
p
I want to transfer my assets from my employer’s co-provider to my ICMA-RC 457 Plan.
Co-Provider Name:_____________________________________________________________________________________________________
Employer Plan Name:___________________________________________________________________________________________________
Co-Provider Plan Phone Number:_________________________________________________________________________________________
Co-Provider Plan Address:
_______________________________________________________________________________________
________________________________________________________________________________________
Participant account number: _____________________________________________________________________________________________
3b
Transfer
Amount
(must be
completed)
3c
Source of
Transfer
Assets
(must be
completed)
I wish to liquidate and transfer: p
OR
p
100% of my account balance (Estimated Transfer Amount $ _____________________)
The following portion of my account in the manner specified below:
Fund Name
Dollar Amount
Fund Name
Dollar Amount
1) ______________________________________
_____________
3) ________________________________________ _____________
2) ______________________________________
_____________
4) ________________________________________ _____________
In order to ensure accurate record keeping and tax reporting, ICMA-RC must receive accurate information regarding the source of the
assets being transferred. The provider sending the assets to ICMA-RC must report the amounts of the different types of assets separately on
the check stub or other documentation.
Please check one of the following options. If Box 2 is checked, please provide additional details in the space provided:
1)
2)
p457 plan deferrals (and associated earnings) through my current employer only
pThe transfer includes rollover assets from another plan (e.g., a previous employer’s retirement plan)
(Provide additional details below)
p
p
p
457 plan deferrals (and associated earnings) through my current employer
$__________________ (insert amount from this source)
457 plan rollovers (from a previous employer’s 457 plan)
$__________________ (insert amount from this source)
Qualified plan rollovers (rollover assets from a 401(a), 401(k), 403(b), or IRA)
$__________________ (insert amount from this source)
Important Notice: Providing inaccurate or incomplete information could result in tax consequences.
ICMA-RC • P.O. Box 96220 • Washington, DC 20090-6220 • Toll Free 800-669-7400 • En Español llame al 800-669-8216 • www.icmarc.org • Fax 202-682-6439
2
FRM000-100-201012-917
457 CO-PROVIDER TRANSFER TO ICMA-RC FORM - Page 2 of 3
4
Investment
Allocation
Employer Plan Number
Social Security Number
___ ___ ___ ___ ___ ___
___ ___ ___ - ___ ___ - ___ ___ ___ ___
The transferred assets will be invested in your account according to your allocation instructions for each source (e.g., contributions, rollovers) of funds received, provided that ICMA-RC receives documentation confirming the source of the funds. However, if the documentation confirming the source of the assets is not included with the transfer, the assets will be invested according to the instructions on file for
rollover source assets.
In the absence of valid allocation instructions for a particular source of funds, assets will be invested according to the allocation instructions for the investment of contributions to your account (or to the default fund selected by your employer, if you have not yet provided
allocation instructions for the investment of contributions to your account).
ICMA-RC will send you a confirmation notice when the transferred assets have been received and credited to your account. You will have
the ability to transfer your assets to any investments available within your plan at any time by contacting ICMA-RC at 800-669-7400 or
by accessing your account online at www.icmarc.org.
New York State 457 Deferred Compensation plans: If your 457 plan account is with an employer in New York State, the transferred assets will be invested according to the same allocation instructions that are used for the investment of contributions to your account
(or to the default fund selected by your employer, if you have not yet provided allocation instructions for the investment of contributions to
your account).
5
Investor
Signature
I acknowledge that I have read and agree to the disclosures shown in the instructions for this section. I have also read and agree to the
process described in Section 4 of this form relating to how the transferred assets will be invested within my account.
I authorize and request the custodian of my existing retirement plan specified in Section 3a to liquidate and transfer my existing account to
the ICMA-RC account specified in Section 2 of this form.
_______________________________________________________________
Signature
6
Employer
Authorization
for Co-provider
Transfer
7
Signature
Guarantee
Date______ _____ /______ _____ /_____ _____ _____ _____
Month
Date
Year
Please obtain signature of the employer sponsoring the plan into which you are transferring assets.
________________________________________________________________
Current Employer Authorization
Date ______ _____ /______ _____ /_____ _____ _____ _____
Month
Date
Year
Signature Guarantee
Some plan providers require a signature guarantee on the transfer request form (ICMA-RC does not). Please check with the co-provider to
see if they require a signature guarantee, as the lack of a required signature guarantee may delay the processing of your transfer request.
Signature guarantees can be obtained at most local banks.
Authorized Officer to Place Stamp Here
_____________________________________________
Guarantor
_____________________________________________
Title
ICMA-RC • P.O. Box 96220 • Washington, DC 20090-6220 • Toll Free 800-669-7400 • En Español llame al 800-669-8216 • www.icmarc.org • Fax 202-682-6439
3
FRM000-100-201012-917
457 CO-PROVIDER TRANSFER TO ICMA-RC FORM - Page 3 of 3
7a
ICMA-RC Use
ONLY
Employer Plan Number
Social Security Number
___ ___ ___ ___ ___ ___
___ ___ ___ - ___ ___ - ___ ___ ___ ___
______________________________________________
___ ___
Representative that verified ID Month
/ ___ ___ / ___ ___ ___ ___ Year
Day
______________________________________________
Type of ID
7b
Rep Comments for Internal Use
Only
8
ICMA-RC/ICMARC Services
Authorization
(Please Do Not
Complete)
p No LOA needed
ICMA-RC/ICMA-RC Services hereby attests that it maintains an eligible 457 plan account for the above named individual and will
accept the above referenced transfer of assets.
__________________________________________________________________________
Authorized Signature, ICMA-RC/ICMA-RC Services
9
Document
Mailing and
Check/Wire
Instructions
for Former
Trustee/
Custodian
Send all Forms to:
Send checks to:
ICMA-RC
Attn: Workflow Management Team
PO Box 96220
Washington, DC 20090-6220
Fax: 202-682-6439
Assistant Secretary
Title
Send wire transfers to:
Vantagepoint Transfer Agents/457
c/o M & T Bank
P.O. Box 64553
Baltimore, MD 21264-4553
M & T Bank
ABA #022000046
Vantagepoint Transfer Agent/457
Account # 42538001
Please reference: 30XXXX (six-digit plan # beginning with “30” specified in Section 2), investor name and SSN on check/wire.
ICMA-RC • P.O. Box 96220 • Washington, DC 20090-6220 • Toll Free 800-669-7400 • En Español llame al 800-669-8216 • www.icmarc.org • Fax 202-682-6439
FRM000-100-201012-917
4