Portfolio Builder 1234
Exchange/Direct Rollover Form
Important Notice: New rules regarding the movement of Plan-to-Plan Transfer: Upon separation of service you may
403(b) assets became effective September 25, 2007. Please elect to move your 403(b) assets to a 403(b) with your new
be sure to consult with your financial or tax advisor prior 403(b)-eligible employer. Both your prior employer and your new
to initiating a contract exchange. employer must allow for plan-to-plan transfers. If the plan-to-
plan transfer satisfies the requirements of the Internal Revenue
Please contact your employer or the resigning Trustee/ Code, it will be a non-reportable transaction. These transferred
Custodian for additional forms or requirements prior assets are subject to all plan rules of the receiving plan.
to submitting this form. All pertinent information must
Change of Investment: Transferring from one approved provider
be completed in order to expedite the request. to another approved provider.
Contract Exchange: If you have not experienced a qualifying
Note: You must complete a separate form for each investment
event such as separation from service, disability or attainment of
company from which you are transferring assets.
age 59½, and you wish to transfer your 403(b) assets within your
current employer’s plan from one provider to another approved This form is to be used:
provider or a “contract exchange” provider, you may do so via a l To roll over an eligible retirement plan or IRA to an
contract exchange. A contract exchange provider is one that is OppenheimerFunds 403(b)(7) (Direct Rollover)
permitted to accept exchanges but not approved for ongoing
contributions. If the contract exchange satisfies the requirements of l To initiate a contract exchange of your current employer’s
the Internal Revenue Code, it will be a non-reportable transaction. 403(b) with another Custodian to an OppenheimerFunds
Please note that you may only execute a contract exchange to a 403(b)(7) (Trustee-to-Trustee transfer/change of Trustee)
provider your current employer has named as an approved pro- l To initiate a plan-to-plan transfer from your prior employer’s
vider or with whom it has an Information Sharing Agreement (ISA). 403(b) plan to an OppenheimerFunds 403(b)(7) plan
Direct Rollover: Upon experiencing a qualifying event l For change of investment from an approved provider to
(separation from service, disability or attainment of age 59½), you another approved provider
may move assets to another 403(b) account, subject to certain
conditions. This is a reportable event. Rollover assets may be
subject to different distribution rules in the receiving plan. Please print clearly in all CAPITAL LETTERS using black ink.
Color in circles completely. For example: not x not ✓
1 | Account ownership
First name Middle initial Last name Mr. Mrs. Ms. Social Security number
Current Employer: ________________________________________
Prior Employment (If executing a Plan-to-Plan Transfer): ________________________________________
Type of current Retirement Account you are rolling over from:
IRA SEP IRA SARSEP SIMPLE IRA
401(k) 403(b) Defined Benefit Plan Profit-sharing Plan
457 Money Purchase Pension Plan Other _________
Do we need to solicit for the funds? Yes No
If no, please initial:
I understand I am responsible for sending the money to OppenheimerFunds: __________.
Estimated amount of transfer: __________.
RE0001.028.0110 Page 1 of 4
2 | Transfer options
Note: Rollovers and Please select the type of transaction you are initiating. Please refer to the definitions on page 1 to be sure you
transfers are permitted from are selecting the correct transaction type.
Traditional IRAs, SEP IRAs, Contract Exchange Direct Rollover Plan-to-Plan Transfer Change of Investment
SIMPLE IRAs (after two
years), Qualified Plans, Check one of the following:
Traditional 403(b) and 457 I am opening a new OppenheimerFunds Portfolio BuilderSM 403(b)(7) account and have attached a Portfolio
Plans into a Traditional Builder 403(b)(7) account application form. (I have made my fund selections on that form.)
403(b) Plan. Conversions
from a Traditional Please invest proceeds in my existing OppenheimerFunds 403(b)(7) account using the fund allocation in my
401(k)/403(b) to a Roth existing Portfolio Builder account.
401(k)/403(b) plan are Please indicate the Portfolio Builder account number associated with this existing 403(b)(7) account:
3 | Resigning trustee, custodian or financial institution information
If your account contains shares A. General Information
of Oppenheimer funds, you
may choose to transfer them ( )
over “in kind” by completing
Name of Current Trustee/Custodian Business phone number
Sections 3A and 4.
Please provide a breakdown of ( )
money types being transferred Street address Fax number
via Contract Exchange, Plan-
to-Plan Transfer or Change of
Investment. You may provide City
this information on the check
itself or provide a copy of this
page when sending the check State Zip
B. Redemption Instructions
If this information is not
will treat the assets to be 1. Resigning Trustee/Custodian Account number (If you have more accounts, please attach a separate sheet.)
the most restrictive for
distribution purposes. Please liquidate immediately from the account listed above and issue a check made payable to OFI Trust
For Roth transfers only: Company (see Section 1 for address).
Failure to provide a breakdown Liquidate All or
of deferrals versus earnings Partial
will result in the check
being returned to the _________________ _% or $_________________ _
2. For CDs and Passbook Savings only (see Section 1 for address):
Liquidate All or
Immediately. I am aware of and acknowledge the penalty I may incur for early withdrawal from a
passbook or a CD.
At Maturity Date__________________
(must be within 30 days) Month/Day/Year
3. Money Type Certification—Required for Contract Exchange, Plan-to-Plan Transfer and Change of Investment
A. Employee Traditional Deferrals $____________________
B. Employee Roth Deferrals $____________________
Roth Estimated Earnings $____________________
C. Employer Contributions $____________________
D. Rollover Contributions $____________________
RE0001.028.0110 Page 2 of 4
C. To Resigning Trustee/Custodian—For Roth Transfers Only
Please issue a separate distribution check for each type of money with the check notating the type of money.
If you are not able to provide separate checks, please complete the information listed on the previous page and
send it with the check. Breakdown of the information must be as of the date the liquidation occurs.
Signature of Resigning Trustee/Custodian
4 | Transfer-in-kind instructions
Complete this section only if Please transfer my funds “in kind” immediately.
you currently have an existing
retirement plan account at All or Partial amount of shares __________________
want to change your current
From Resigning Trustee/Custodian Fund and Account Number
OppenheimerFunds shares may
be rolled over in kind. You may At the request of our retirement plan account holder (as identified above), the resigning Trustee/Custodian asks
expedite this transfer by including OppenheimerFunds Services, as Transfer Agent, to transfer the registration of the shares of the Oppenheimer
a Letter of Instruction from fund(s) listed above, presently registered in our names as Trustee/Custodian for a retirement plan identified
your current Trustee/Custodian above, for the benefit of the referenced individual.
approving this Transfer-in-kind.
If you have more accounts, please attach a separate sheet with the information required in this section.
5 | Required minimum distribution information
If you are a beneficiary of this Were there multiple beneficiaries on the account? Yes No
account and are receiving
distributions, please complete If yes, was the account split by September 30th of
the following. Additional the year following the original account owner’s death? Yes No
information may be required. What was the age of the oldest beneficiary of the account including yourself, on December 31st of the year
following the year of the original account holder’s death? Age: _________________ _
Are you the spouse of the original account holder?
No Yes Your Date of Birth: _________________ _
How are you currently taking distributions?
Five-year Method Life Expectancy Method
What was the year of death of the original account holder? _________________ _
Please provide the Social Security number and Date of Birth of the original account holder.
Social Security number
Date of Birth (mm/dd/yyyy)
Please note: If you wish to take a distribution from this OppenheimerFunds Portfolio Builder 403(b)(7)
account, you must complete an OppenheimerFunds Distribution Request Form.
6 | Contract exchange
Please complete this section I hereby request a liquidation and a tax-free contract exchange in the above-referenced Tax-sheltered Annuity
if you are transferring your Contract(s)/Tax-sheltered Custodial Account(s) to a custodial account(s) with OppenheimerFunds. This custodial
403(b) account to the account has been established for me in accordance with Section 403(b)(7) of the Internal Revenue Code of 1986,
as amended (the “Code”). I have established a 403(b)(7) Custodial Account Plan with OppenheimerFunds
account via a contract exchange
(formerly a 90-24 transfer). and have appointed the Custodian of such 403(b)(7) Custodial Account Plan as the successor Custodian. This
will be a tax-free transfer made in accordance with applicable IRS and Treasury regulations.
Check here if you have an outstanding loan obligation in your current 403(b) account that you wish to transfer
to your OppenheimerFunds 403(b)(7) account. Defaulted loans may be transferred to OppenheimerFunds
only if they have been fully repaid prior to transfer. The unpaid or partially repaid defaulted loan obligation(s)
must remain at the originating 403(b) or 403(b)(7) account. Please complete the 403(b)(7) Loan Transfer
Form and submit it along with this form to transfer your loan obligation.
RE0001.028.0110 Page 3 of 4
7 | Signature
Please check with your I hereby grant permission to the resigning trustee to release information pertaining to my account.
resigning Trustee or Custodian
to determine if a signature I hereby authorize OFI Trust Company as the custodian named on my 403(b)(7) account to share information
guarantee is required and with an authorized representative of the employer under which this 403(b)(7) account is established relating to
what type of institution is my 403(b)(7) account(s) held under this Custodial agreement. I understand that this information exchange is
acceptable as guarantor. necessary to enable the employer to satisfy the requirements of Section 403(b) of the Internal Revenue Code
and to maintain the tax-favored status of my plan.
In executing this 403(b) contract exchange, I understand and acknowledge that its validity is contingent on
the employer under which this account is established (a) permitting such contract exchanges in the 403(b)
plan and (b) naming the accepting custodian as an approved provider under the plan or entering into a valid
agreement to share information relating to this plan for purposes of complying with the requirements under
Section 403(b). I understand if such requirements are not met, it may result in all of my 403(b) assets under this
employer’s plan becoming taxable and subject to possible penalties.
Name of Participant (Please print)
Signature of Participant Date
Name of Guarantor (Please print) Title of Guarantor
Signature of Guarantor Date
Signature Guarantee Stamp
8 | Employer authorization
Note to Employer: If your plan I hereby approve the above-referenced distribution request and certify that the participant has met all
is subject to ERISA, spousal requirements, including any applicable spousal consent requirements.
consent may be required prior
to authorizing a distribution
from the 403(b) plan. X
Employer or Authorized Designee Signature
9 | Acceptance of transfer
Do not complete below. The Trustee cannot accept stock certificates. Please liquidate and send cash, or complete Section 4 for a
To be filled out by transfer-in-kind.
as agent for OFI Trust Company. To the resigning Trustee/Custodian: Above are instructions from your client to liquidate or transfer-in-kind
proceeds of the referenced retirement plan account to an OppenheimerFunds 403(b) plan, as identified above.
We have established a retirement plan account for the said individual under Section 403(b) of the Internal
Revenue Code of 1986, as amended, and we hereby agree to accept the assets you transfer and to hold these
assets in a retirement account for the benefit of the individual referenced above. In addition, OppenheimerFunds
represents that it is either an approved provider under the plan or it has entered into an appropriate agreement
to share information with the participant’s employer for purposes of meeting the requirements of section 403(b)
of the Code and applicable Department of Treasury regulations issued thereunder.
To ensure proper credit, please make check payable to: OFI Trust Company, Trustee
OppenheimerFunds Authorized Signature Date
Please return completed application (and check, if applicable) to:
OppenheimerFunds Distributor, Inc.
P.O. Box 5390
RE0001.028.0110 February 10, 2010 Denver, CO 80217-5390
Phone: 1.800.835.7305 Fax: 1.303.768.1500
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