Fillable Printable Form RI 38-122
Fillable Printable Form RI 38-122
Form RI 38-122
Alternative Annuity and Rollover Election
Name (last, first, middle) Social Security Number
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Please read all of the information in the Alternative Annuity Election Information For
Employees, Form RI 38-123, before completing this form.
I. Alternative Annuity
I do not want to make an election at this time. I want OPM to send me the complete alternative annuity election package.
I understand my application for retirement will not be processed until after I receive and return the election form.
Provide your signature below and return this form to your Personnel Office. Do not check any of the following blocks.
Your signature Date
I elect to receive a reduced alternative annuity and a lump-sum payment of my retirement contributions. If I am married,
the consent of my spouse is shown below in Part II. I do not have a former spouse who is entitled by court order to a
portion of my annuity or a survivor annuity.
II. Spousal Consent
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Your spouse must sign in the presence of a notary or other person authorized to administer oaths.
I freely consent to this alternative annuity election.
Signature of current spouse
NotarizationβTo be completed by notary public or other official authorized to administer oaths.
I certify that the person whose signature appears immediately above presented
identification (or was known to me), gave consent to the specific election as executed by
the employee, signed or marked the form, and acknowledged that the consent was freely
given in my presence.
(Seal)
Signature Expiration date of commission Date
III. Rollover Election
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Complete one of the following options
Pay my lump sum directly to me. I understand that the Office of Personnel Management is required to withhold 20% of
any taxable portion for Federal income tax and that to defer income tax I have the option to roll over part or all of any
taxable portion within 60 days after receipt into a traditional IRA or an eligible employer plan.
Pay $_________ (enter "all" or a dollar amount at or above $500) of my lump sum to ____________________________
with no Federal income tax withheld from any taxable portion.
Is this a Roth IRA?
Yes No
Do you elect to have Federal income tax withheld?
Yes No
Pay any remainder to me, less 20% Federal income tax withholding from any taxable portion paid to me.
Send the payment to my account. Send the payment to me, made payable to my account. I will
deliver it to the account within 60 days.
Provide your certification: By my signature below, I certify that I have read and understood the information in the
accompanying Alternative Annuity Election Information For Employees notice. I certify that I do not have a former spouse
entitled by court order to receive a portion of my annuity or a survivor annuity.
Warning: Any intentionally false or willfully misleading statement or response you provide in this election is a violation of
the law punishable by a fine of not more than $10,000 or imprisonment of no more than 5 years, or both. (18 U.S.C. 1001)
Signature Date
(Continued on reverse)
RI 38-122
This form may be locally reproduced
Revised August 2010
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IV. Certification by Financial Institution or Eligible Employer Plan
Name of institution or eligible employer plan Address of institution or plan
IRA account number or plan identification
Certification: My signature below confirms the account number for the individual named on page 1. As a representative of the financial
institution or plan named above, I certify that this institution or plan agrees to accept the funds described above as a direct
trustee-to-trustee transfer from the Office of Personnel Management, to deposit them in an eligible IRA or eligible employer plan as
defined in the Internal Revenue Code, and to account for these monies in compliance with the Internal Revenue Code. I understand that
my signature below authorizes the transfer of taxable and/or non-taxable funds as indicated on page 1.
Typed or printed name of certifying representative Telephone number (including area code)
Signature of certifying representative Date of certification (mm/dd/yyyy)
Name of institution or eligible employer plan Address of institution or plan
IRA account number or plan identification
Certification: My signature below confirms the account number for the individual named on page 1. As a representative of the financial
institution or plan named above, I certify that this institution or plan agrees to accept the funds described above as a direct
trustee-to-trustee transfer from the Office of Personnel Management, to deposit them in an eligible IRA or eligible employer plan as
defined in the Internal Revenue Code, and to account for these monies in compliance with the Internal Revenue Code. I understand that
my signature below authorizes the transfer of taxable and/or non-taxable funds as indicated on page 1.
Typed or printed name of certifying representative Telephone number (including area code)
Signature of certifying representative Date of certification (mm/dd/yyyy)
Instructions for Rollover to the Federal Retirement Thrift Savings Plan
The Thrift Savings Plan (TSP) will not accept non-taxable (post-tax) monies. You must have an open TSP account. Before
the Office of Personnel Management (OPM) can complete a rollover to your Thrift Savings account, you must sign and submit
Form TSP-60, Request for a Transfer into the TSP, to OPM. Submit both the TSP-60 and this form at the same time. OPM
will complete its portion of the TSP-60 and fax it to the Thrift Savings office for processing. The form must be approved by
the Thrift Savings Board and the Board must notify OPM to transfer the funds. This process can take two to three weeks. Form
TSP-60 is available on the internet at www.tsp.gov/forms.
Privacy Act Statement
Solicitation of this information is authorized by Chapters 83 and 84, title 5, U.S. Code. The information you furnish will be used to obtain
additional information, if necessary, and to determine and allow present or future benefits. The information may be shared and is subject to
verification via paper, electronic media, or through the use of computer matching programs, with national, state, local, or other charitable or
social security administrative agencies in order to determine benefits under their programs, to obtain information necessary for
determination of benefits under this program, or to report income for tax purposes. It may also be shared or verified, as noted above, with
law enforcement agencies when they are investigating a violation or potential violation of civil or criminal law. Executive Order 9397
(November 22, 1943) authorizes the use of the Social Security Number. Furnishing this information is voluntary, but failure to do so will
delay or make it impossible for OPM to pay your alternative annuity lump sum.
Reverse of RI 38-122
Revised August 2010
