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ACCEPTANCE OF CUSTODIAN TRUSTEE An Affirmative Action

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An Application for Withdrawal may not be rescinded after the end of the calendar month in which TRB receives it. Please note this will be considered your one time withdrawal* Applicant s Last Name First Name Middle Initial Address Street Home Phone Fax City Applicant s SS State E-Mail Zip Code Maiden Name if applicable CHECK ONE ELECTION Rollover - I elect to have Teachers Retirement Board rollover the taxable portion of the account balance s remaining directly to the Qualified Plan indicated ...

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