Alternative Annuity and Rollover Election Name (last, first, middle) Social Security Number 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 forms. 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 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 Notarization—To 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. Signature Expiration date of commission (Seal) Date III. Rollover Election Complete one of the following options Pay my lump sum directly to me. I understand that 20% of the taxable amount of the lump sum will be withheld for tax but that to defer income tax, within 60 days I can rollover part or all of the taxable amount to a qualified account. I want (enter "all" or a dollar amount at or above $500) __________ of the taxable amount of my lump sum made payable to the account shown below with no tax withholding. I understand that any balance made payable to me will be subject to 20% tax withholding, but that to defer income tax, within 60 days I can roll any part of it over to a qualified account. If you check this block, your financial institution must complete Part IV. 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) This form may be locally reproduced RI 38-122 Revised December 2005 American LegalNet, Inc. www.FormsWorkFlow.com IV. Certification by Financial Institution or Eligible Employer Plans 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 name 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 name 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. Form TSP-60 is available on the internet at http://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 December 2005 American LegalNet, Inc. www.FormsWorkFlow.com