Rollover Contribution Form (Page 2 of 2) in pdf

ROLLOVER CONTRIBUTION FORM

INVESTMENT FUND ELECTIONS (MUST TOTAL 100%)

If you do not designate fund elections or elections do not total 100%, an investment allocation does not exist for the money type being rolled, your rollover

contribution allocation will default to Voya Fixed Plus III¹. Please refer to the Plan Highlights and Fund Fact Sheets located at for additional

information about the CalSTRS Pension2 Program, Voya Fixed Plus III¹ and the mutual fund investment options.

VOYA FIXED PLUS III

________

VANGUARD MID CAP INDEX

________

.00%

FEDERATED US TREASURY CASH

________

ESG MANAGERS GROWTH INST

________

.00%

VANGUARD TOTAL BOND MARKET

________

GMO GLOBAL EQUITY ASSET

________

.00%

VANGUARD SHORT-TERM BOND INDEX

VANGUARD EMERGING MARKETS

________

.00%

VANGUARD INFLATION PROTECTED

VANGUARD DEVELOPED MARKETS

________

.00%

VANGUARD TOTAL STOCK MARKET

DODGE AND COX INTERNATIONAL

________

.00%

VANGUARD INSTITUTIONAL INDEX

________

DFA INTERNATIONAL SMALL CO

________

.00%

TIAA-CREF SOCIAL CHOICE EQUITY

________

ARTISAN INTERNATIONAL

________

.00%

DODGE AND COX STOCK

________

VANGUARD REIT INDEX

________

.00%

AMERICAN GROWTH FUND

________

PIMCO ALL ASSET

________

.00%

TOTAL

100%

VANGUARD SMALL CAP INDEX

________

.00%

AUTHORIZATION

I certify that the amount of my rollover contribution represents only money that is eligible to be rolled over into the CalSTRS Pension2 Program.

If any of the money is subsequently determined to be ineligible for rollover, I understand that the Plan will distribute the ineligible amount and

any attributable earnings, if applicable.

PARTICIPANT SIGNATURE __________________________________________________________ DATE _____________________

If you have any questions, please go online at or call the CalSTRS Pension2 Service Center at 1-844-353-2872 (TTY/TTD users

call 1-800-468-5449). Customer Service Associates are available Monday through Friday, 6:00 A.M. to 5:00 P.M. Pacific Time (excluding

stock market holidays).

CHECKLIST

PLEASE REVIEW YOUR APPLICATION CAREFULLY.

If your application is complete, please mail

the application to:

Completed the Personal Information

section, and

VIA MAIL

Contacted your former employer or financial institution,

and

Voya Financial

Completed the Investment Fund Elections section,

and

Attn: CalSTRS Pension2 Plan Administration

Included your rollover check (made payable to CalSTRS Pension 2 Plan, F.B.O. (Your Name)),

and

P.O. Box 55772

Boston, MA 02205-5772

Included proof of plan qualification documenting the source of your rollover contribution such as: 401(k),

403(b), 457 or IRA (IRS Letter of Determination, letter from plan’s prior record keeper, and rollover

VIA OVERNIGHT DELIVERY

distribution statement),

and

Voya Financial

Attn: CalSTRS Pension2 Plan Administration

Included proof of taxability detailing the taxability of funds to be rolled over such as: pre-tax, non-Roth,

30 Braintree Hill Office Park

after-tax, designated Roth. (Letter from plan’s prior record keeper, and/or rollover distribution

Braintree MA 02184

and

statement),

Signed and dated the Rollover Contribution form

If your rollover check or any of the above required information or documentation is missing from your

application, there will be a delay in processing your rollover contribution and your application and/or

check may be returned to you.

Voya Fixed Plus III is offered through a group annuity contract issued by Voya Retirement Insurance and Annuity Company, P.O. Box 990063, Hartford, CT 06199-0063.

ROLLOVER CONTRIBUTION FORM / PAGE 2 of 2

CZ400CZ1ROLLVRY

12/14/2015

Rollover Contribution Form Page 2

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