Department of Consumer and Business Services - State of Oregon 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section A: Applicant Information. Fill in your first name, middle initial, last name, Social Security number, and PERS ID. Ensure all entries are clear and legible to avoid delays.
3. Move to Section B: Rollover Acceptance. Indicate whether the plan will accept after-tax dollars by checking the appropriate box.
4. In Section C: Rollover Account Information, provide the financial institution's name, mandatory rollover account number, and specify the rollover plan type.
5. Proceed to Section D: Rollover Mailing Address and Confirmation. Enter your address, city, state, zip code, along with your name and title.
6. Finally, complete Section E: Authorized Signature. Sign and date the form to indicate acceptance of the rollover contributions and earnings.

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