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Service Retirement Application

Customer Name: JOHN DOE

Defined Benefit Supplement (DBS) Distribution: Tax-Deferred Rollover

Complete the requested information below to request a rollover of your DBS Distribution — tax-deferred contributions and interest to the financial institution of your choice.

Once you have made your selections, choose the Next button to continue.

Tax-Deferred Contributions & Interest

(dynamic) Total Available for Rollover: $2012.50

(dynamic) Total Monthly Available for Rollover: $2012.50

  The amount displayed is the total amount of your DBS Distribution as tax-deferred contributions and interest available for rollover.  
 

Make Your Rollover Selection

 
  I elect a rollover of my DBS Distribution — tax-deferred contributions and all interest to the qualified trust plan listed below. Tax will not be withheld from the portion of the distribution that is rolled over. Any monies not designated for transfer will be mailed to me.  

Select One*

Traditional IRA

Roth  (Roth IRA, Roth 403(b))
Be Advised (dynamic)
Rolling over tax-deferred funds into a Roth IRA or Roth 403(b) is a taxable event. CalSTRS will not withhold taxes and will report the rollover on a 1099. You may want to consult a tax professional before completing this application.

Eligible Rollover Plan  (403(b), 457, 401(k) or 401(a))
 

Specify Your Transfer Amount

 
  *Enter the Amount to Transfer or specify a Percentage to Transfer of the Total Available for Rollover listed above.  
 
Amount to Transfer: $
Percentage to Transfer: %
 
Be Advised
If you intend to rollover your entire balance please specify 100% not a dollar amount.

Indicate Your Financial Institution

Tell us which financial institution you would like your rollover to be mailed to for your DBS Distribution. A check for the transfer amount will be processed and mailed to the financial institution you provide below. Keep the account open for at least 12 months.

Select your financial institution from the drop down menu below.
* Financial Institution:
  
Pension2 (dynamic)
CalSTRS Pension2® is a supplemental savings plan that offers several investment choices to California school employees such as: 403(b), 457 and Roth 403(b). Learn more about Pension2. external link
  * Name of Institution:
  
  * Street Address:
  
  Suite #:
  
  * City:
  
  * State:
  
  * Zip Code:
   -
  * Primary Phone Number:
   () - Ext.

Your Account Number

Enter your account number with the financial institution you are requesting the rollover to be transferred to.
  Account Number:  
     

* Required fields to continue.
       
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