Form Rs2416 - Application For Direct Trustee-To-Trustee Transfer For Purchase Of Service Credit
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1Application for Direct Trustee-to-Trustee
Office of the New York State Comptroller
Thomas P. DiNapoli
Transfer for Purchase of Service Credit
New York State and Local Retirement System
Employees’ Retirement System
Police and Fire Retirement System
RS2416
110 State Street, Albany, New York 12244-0001
Phone: 1-866-805-0990 or 518-474-7736
Fax: 518-402-4433
(Rev. 12/13)
Email: nyslrsinfo@osc.state.ny.us
Web:
For the purchase of optional and previously withdrawn service only.
Complete the section below and mail this form with a copy of your arrears cost letter to the administrator of the
retirement account or plan from which you are transferring funds.
MEMBER INFORMATION (to be completed by member)
Name (Please Print) _______________________________________________
Social Security Number __________________________
Home Address ___________________________________________________
Retirement Registration Number ___________________
City ________________________________ State ______ Zip __________
Date of Birth____________________________________
Work Telephone Number ___________________________________________
Home Telephone Number_________________________
I authorize the transfer of $ ________________________ to be received no later than ________________. The transfer does not
include after-tax contributions, nor is the amount greater than the amount quoted on the cost letter for the purchase of service.
I assume responsibility for any tax consequences that result if the certifications on this form are not correct.
_______________________________________________________________________________
Date ___________________________
Member Signature
TRUSTEE INFORMATION (to be completed by trustee)
Trustee Name (Please Print) _________________________________________
Please indicate the transferring plan type:
Individual Retirement Account - 408(a) -or-
Trustee Address __________________________________________________
Individual Retirement Annuity - 408(b)
City ________________________________ State ______ Zip __________
403(a) Annuity Plan
403(b) Tax-Sheltered Annuity
Qualified Defined Benefit or Contribution Plan
401(a) or 401(k)
Governmental Deferred Compensation Plan - 457
Account Number _________________________________________________
Name & Title of Authorized Plan Administrator (Please Print) _______________________________________________________________
Transfers from Inherited IRAs, Roth IRAs and Inherited Roth IRAs are not permitted.
_______________________________________________________________________________
Date ___________________________
Signature of Authorized Plan Administrator
Please return the completed form to the address below and enclose a check payable to NYSLRS.
NYSLRS
Attn: Member Accounts
110 State St
Albany, NY 12244
Fax: 518-408-5569
The New York State and Local Retirement System (NYSLRS) is a qualified plan under Section 401(a) of the Internal Revenue Code.
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