Fillable 457(b) Plan Transaction Request Form

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457(b) Plan Transaction Request Form

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Page 1 of 2
TCGADM0320 – 457(b)
457(b) Plan Transaction Request Form
A. INFORMATION ABOUT THE PARTICIPANT (OR BENEFICIARY IF DEATH CLAIM)
Full Name
Social Security #
Street Address
Date of Birth
Apt/Bldg #
Contact Phone
City, State, Zip
Contact Email
EMPLOYER (Through which you
had this account)
Nonresident Alien?
☐ YES ☐ NO
Receive status updates and your Record ID via Text Message
Message & Data rates may apply
Mobile Phone #
B. REASON FOR DISTRIBUTION (MUST SELECT ONE REASON)
☐ No Longer Employed by Employer Listed Above
Date of Separation:
☐ Attainment of Age 59.5
☐ Death of Participant
Please provide Death Certificate; subject to further review
☐ Required Minimum Distribution
If you turned 70.5 in 2019 and were subject to a RMD, you will need to
continue to take a RMD in 2020.
Participant is age 72 or older and is separated from employer
(New Age requirement effective 1/1/2020)
☐ Transfer to Purchase Service
Please submit a form showing the public pension plan that funds are
being transferred to
☐ Permanent & Total Disability of Participant
Date became Disabled:
☐ Unforeseeable Emergency
Complete Verification Form (See following forms)
☐ Inservice Withdrawal for Birth or Adoption of a Child
Supporting documentation required upon submission
☐ Disaster Relief
Complete attached Appendix B
☐ CARES ACT Relief – In-service distribution due to
Coronavirus
Complete attached Appendix C
900 S Capital of TX Hwy, Ste. 350
Austin, TX 78746
457@tcgservices.com
P: 800.943.9179 F: 888.989.9247
Please submit completed form via fax, email or mail
Sections A-D must be complete for processing
C. DISTRIBUTION INSTRUCTIONS
☐ Cash Distribution
Other than Inservice Withdrawal (see below)
☐ Check box for partial withdrawal of:
Do not check for full distribution
$
All or a portion of your distribution is eligible to be rolled over into another retirement account. Please review the attached Special Tax Notice. If you
choose the cash distribution option, a mandatory 20% (30% for nonresident aliens) federal income tax withholding will be deducted from your
distribution. Federal law requires the automatic Federal income tax withholdings for cash distributions over $200. The distribution check will be made
payable to you and will be mailed to the address provided above.
☐ Rollover to Financial Pathway IRA
If you do not have an IRA but would like to set one up, FinPath IRA is an available resource
at www.finpathira.com . You will be contacted if an account has not yet been set up.
☐ Qualified Rollover or Transfer
(IRA, 403(b), 457(b), 401(k), 401(a), etc.)
Please complete the section on page 2 with the receiving institution’s information or
submit a letter of acceptance along with this form to TCG.
Funds cannot be sent without the receiving institution’s information.
A signature is required on the following page. Electronic signatures will not be accepted.
TCG Administrators – 457(b) Transaction Request Form
Page 2 of 2
TCGADM0320
D. ACCEPTANCE AND AUTHORIZATION (PLEASE SIGN BELOW)
By my signature below, I represent that I am the owner of the account listed above and authorize the distribution of assets as indicated. I understand
that my account will be charged a distribution fee (review your Summary Plan Description at www.tcgservices.com/documents for fee details), and if
my account balance is less than the distribution fee, I will not receive any money.
Signature of Participant
(or Beneficiary if Death claim)
Date
NOTE: If additional contributions are received after a final distribution has occurred, TCG Administrators will process the second request exactly as
specified on this form and an additional distributions fee will be charged.
Complete this section to complete a
Rollover of funds
Name of Receiving
Institution
Street Address of
Institution
City, State, Zip
Receiving Account/Contract #
Type of Account you are sending
funds to: (IRA, 403(b), 457, etc.)
INSERVICE WITHDRAWALS
☐ Inservice Withdrawal for Birth or
Adoption of a Child
Amount Requested:
($5,000 maximum)
$
If you choose this option, 10% federal income tax withholding will be deducted from
your distribution unless you elect a different tax percentage below:
☐ I elect to withhold Federal Income taxes at the rate of ______% (0%-50%).
☐ Unforeseeable Emergency
Distribution
Must submit the Verification form
Amount Requested:
$
If you choose this option, 10% federal income tax withholding will be deducted from
your distribution unless you elect a different tax percentage below:
☐ I elect to withhold Federal Income taxes at the rate of ______% (0%-50%).
☐ I elect to gross up the withdrawal amount by the percentage above.
☐ Inservice Withdrawal due to Relief
(Disaster or CARES ACT)
Amount Requested:
$
If you choose this option, there is no federal income tax withholding from your
distribution unless you elect a different tax percentage below:
☐ I elect to withhold Federal Income taxes at the rate of ______% (0%-50%).
☐ I elect to gross up the withdrawal amount by the percentage above.
FOR INTERNAL USE ONLY
The Retirement Plan Specialist dedicated to this transaction:
RPS Name
RPS Contact
TCG Administrators, 900 S. Capital of Texas Highway, Suite 350, Austin, TX 78746
Toll Free (800)943-9179 | Fax (888)989-9247 | www.tcgservices.com
457 TCG Unforeseeable Emergency Form (01/2018)
Unforeseeable Emergency Documentation Guidelines
Listed below are examples of the types of proof that can be provided to document the reasons for unforeseeable
emergency distributions listed on the form. Note that the distribution can only be made if the event was unforeseeable,
represents a severe financial hardship and the need for the funds cannot be met by any other means available to the
participant, including (but not limited to) retirement plans, loans, savings or insurance.
(1)
Illness or accident, including related medical expenses;
Example of Proof Required: If the employee has health insurance, the Explanation of Benefits (EOB) from the
employee’s Health Insurance Company, showing the participant’s out-of-pocket medical expense. If the employee does
not have health insurance, the billing or invoice for medical expenses for medical care that would be tax deductible on the
employee’s federal income tax form (whether or not the expenses exceed 7.5% of adjusted gross income).
(2)
Funeral expenses for a member of the Participant’s family;
Example of Proof Required: Billing for payments for burial and/or funeral expenses for the employee’s deceased parent,
spouse, children or dependents;
(3)
The need to prevent the eviction of the Participant from his or her principal residence or foreclosure on the mortgage
of the Participant’s principal residence; or
Example of Proof Required: A letter or other notice from the employee’s mortgage company or landlord showing the
amount and date of payment(s) necessary to prevent the eviction of the employee from the employee’s principal residence
or foreclosure on the mortgage on that residence. The letter or notice must list the expected date of eviction or
foreclosure.
(4)
Casualty loss of property.
Example of Proof Required: Copy of insurance claim (if applicable); billing for expenses for the repair of damage to the
employee’s principal residence that would qualify for the casualty deduction on the employee’s federal income tax form
(whether or not the loss exceeds 10% of adjusted gross income).
(5) Losses or expenses as a result of Hurricane Harvey, Hurricane Irma or Hurricane Maria
If your principal residence or place of employment was located in one of the counties designated by FEMA for
individual assistance (https://www.fema.gov/disasters) relating to damage from Hurricane Harvey, Hurricane Irma, or
Hurricane Maria you are allowed to take a hardship distribution or a loan until January 1, 2019.
TCG Administrators will rely on the self-certification from an employee or former employee as to the need for and
the amount of the hardship distribution, unless TCG Administrators has actual knowledge to the contrary.
Self-Certification Required: Complete Appendix A
Page 1 of 1
TCGADM0118 – 457(b)
Unforeseeable Emergency Verification
A. INFORMATION ABOUT THE PARTICIPANT (OR BENEFICIARY IF DEATH CLAIM)
Full Name
Social Security #
B. REASON FOR DISTRIBUTION FILL IN ONE REASON ONLY
I AM REQUESTING A DISTRIBUTION DUE TO SEVERE FINANCIAL HARDSHIP FOR MYSELF, A DEPENDENT OR AN IMMEDIATE
FAMILY MEMBER RESULTING FROM:
☐ Illness or accident, including related medical expenses
☐ Funeral expenses
☐ Imminent foreclosure or eviction from primary residence
☐ Casualty loss to employee’s Primary Residence (e.g., theft or natural disaster)
D. ACCEPTANCE AND AUTHORIZATION (PLEASE SIGN BELOW)
I
hereby certify that the emergency cannot be relieved through loans, reimbursement or compensation from insurance, liquidation of
my retirement or investment assets, or by stopping my contributions to the Plan.
Under penalty of perjury, I swear that the information provided or attached to this form is true and correct to the best of my knowledge.
Signature of Participant
(or Beneficiary if Death claim)
Date
900 S Capital of TX Hwy, Ste. 350
Austin, TX 78746
457b@tcgservices.com
P: 800.943.9179 F: 888.989.9247
Please submit completed form via fax, email or mail
A transaction request form must accompany this form
C. EXPLANATION
You must provide documentation regarding the distribution requested. The attached form provides guidelines as to what
documentation is needed. You must include this documentation for us to process your request. If you wish to provide additional
information please include this below.
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
TCG Administrators – Appendix B
Page 1 of 1
TCGADM0220 – 457
APPENDIX B
CERTIFICATION
I hereby certify that on ______________ (DATE), my primary residence or place of employment was located in one
of the
counties declared by FEMA as affected by ____________________, respective disaster, and I have a need
arising from the impact of said disaster.
Please provide an explanation below of the need for the disaster relief distribution or loan:
PLEASE NOTE:
TCG Administrators will rely on the self-certification from an employee or former employee as to the need for and the amount
of the disaster distribution, unless TCG Administrators has actual knowledge to the contrary.
In general, the normal spousal consent rules still apply for any disaster relief withdrawals and any distribution made will still be
includible in gross income (can be taxed over 3 years) or repaid back into the plan.
TCG Administrators – Appendix C
Page 1 of 1
TCGADM04072020 – 457
APPENDIX C
CERTIFICATION
I, __________________________________, hereby certify that one of the following is true:
I, my Spouse or my Dependent have been diagnosed with COVID-19; and/or
I have experienced adverse financial consequences as a result of being quarantined, being furloughed or laid off or
having work hours reduced due to such virus or disease, being unable to work due to lack of child care due to such
virus or disease, closing or reducing hours of a business owned or operated by the individual due to such virus or
disease.
I also certify that the withdrawal amount I have requested is equal to the lesser of $100,000, or all of my vested
account balance from my 457(b), 401(k), 403(b), and 401(a) plans of my Employer.
__________________________________________ ______________________________
Signature of Participant Date
PLEASE NOTE:
TCG Administrators will rely on the self-certification from an employee or former employee as to the need for and the amount
of the distribution, unless TCG Administrators has actual knowledge to the contrary.
In general, the normal spousal consent rules still apply for any disaster relief withdrawals and any distribution made will still be
includible in gross income (can be taxed over 3 years) or repaid back into the plan.
900
S Capital of Texas Highway, Suite 350
Austin, TX 78746
Phone: (512) 795-8999 Fax: (512) 795-0414 Toll
Free: (800) 943-9179 Fax: (888) 989-9247
Email: 457@tcgservices.com
SPECIAL TAX NOTICE
REGARDING PLAN PAYMENTS FROM PLANS QUALIFIED UNDER SECTION 401(a) AND 401(k)
PLANS, SECTION 403(a) ANNUITY PLANS, SECTION 403(b) TAX SHELTERED
ANNUITIES/403(b)(7) CUSTODIAL ACCOUNTS AND 457(b) GOVERNMENTAL DEFERRED
COMPENSATION PLANS
You are receiving this notice because all or a portion of a payment you are receiving is eligible to be rolled
over to an IRA or an employer plan, or you have a designate Roth Account that is eligible to be rolled over
to a Roth IRA or a designated Roth account in an employer plan. This notice is intended to help you decide
whether to do such a rollover.
A rollover allows you to continue to postpone taxation of your distribution from an eligible employer plan
until it is paid to you. An "eligible employer plan" includes a plan qualified under section 401(a) of the
Internal Revenue Code, including a 401(k) plan, profit-sharing plan, defined benefit plan, stock bonus plan,
and money purchase plan; a section 403(a) annuity plan; a section 403(b) tax-sheltered annuity; and an
eligible section 457(b) governmental plan.
An eligible employer plan is not legally required to accept a rollover. Before you decide to roll over
your payment to another employer plan, you should find out whether the plan accepts rollovers and, if so,
what documents are required to be completed before the receiving plan will accept a rollover. Even if a
plan accepts rollovers, it might not accept rollovers of certain types of distributions, such as after-tax
amounts. If this is the case, and your distribution includes after-tax amounts, you may wish instead to roll
your distribution
over to a traditional IRA or split your rollover amount between the employer plan in which
you will participate and a traditional IRA.
Once the rollover is completed, the rolled over amount is governed by the rules of the receiving
plan. The receiving plan may restrict subsequent distributions of the rollover amount, such as by not
permitting distributions of the rollover amount while employed, or by requiring your spouse's consent for
any subsequent distribution. Check with the administrator of the plan that is to receive your rollover prior
to making the rollover.
If you have additional questions after reading this notice, you can contact your plan administrator at TCG
Administrators at (888) 989-9247, 900 S Capital of Texas Hwy, Suite 350, Austin, Texas 78746.
YOUR ROLLOVER OPTIONS
This noti
ce describes the rollover rules that apply to payments from the Plan. Some of the rules differ
when you receive a payment from a designated Roth Account. When there is a difference, the rule for
designated Roth Accounts will be provided in a separate paragraph.
Rules that apply to most payments from a plan are described in the “General Information About Rollovers”
section. Special rules that only apply in certain circumstances are described in the “Special Rules and
Options” section.
2
GENERAL INFORMATION ABOUT ROLLOVERS
How can a rollover affect my taxes?
You will be taxed on a payment from the Plan if you do not roll it over. If you are under age 59½ and do
not do a rollover, you will also have to pay a 10% additional income tax on early distributions (unless an
exception applies). However, if you do a rollover, you will not have to pay tax until you receive payments
later and the 10% additional income tax will not apply if those payments are made after you are age 59½
(or if an exception applies).
Designated Roth Account
After-tax contributions included in a payment from a designated Roth account are not taxed, but earnings
might be taxed. The tax treatment of earnings included in the payment depends on whether the payment
is a qualified distribution. If a payment is only part of your designated Roth account, the payment will
include an allocable portion of the earnings in your designated Roth account.
If the payment from the Plan is not a qualified distribution and you do not do a rollover to a Roth IRA or a
designated Roth account in an employer plan, you will be taxed on the earnings in the payment. If you are
under age 59½, a 10% additional income tax on early distributions will also apply to the earnings (unless
an exception applies). However, if you do a rollover, you will not have to pay taxes currently on the earnings
and you will not have to pay taxes later on payments that are
qua
lified distributions.
If the payment from the Plan is a qualified distribution, you will not be taxed on any part of the payment
even if you do not do a rollover. If you do a rollover, you will not be taxed on the amount you roll over and
any earnings on the amount you roll over will not be taxed if paid later in a qualified distribution.
A qualified distribution from a designated Roth account in the Plan is a payment made after you are age
59½ (or after your death or disability) and after you have had a designated Roth account in the Plan for at
least 5 years. In applying the 5-year rule, you count from January 1 of the year your first contribution was
made to the designated Roth account. However, if you did a direct rollover to a designated Roth account
in the Plan from a designated Roth account in another em
ployer p
lan, your participation will count from
January 1 of the year your first contribution was made to the designated Roth account in the Plan or, if
earlier, to the designated Roth account in the other employer plan.
Where may I roll over the payment?
You may roll over the payment to either an IRA (an individual retirement account or individual retirement
annuity) or an employer plan (a tax-qualified plan, section 403(b) plan, or governmental section 457(b)
plan) that will accept the rollover. The rules of the IRA or employer plan that holds the rollover will determine
your investment options, fees, and rights to payment from the IRA or employer plan (for example, no
spousal consent rules apply to IRAs and IRAs may not provide loans). Further, the amount rolled
over wil
l
become subject to the tax rules that apply to the IRA or employer plan.
Designated Roth Account
You may roll over the payment to either a Roth IRA (a Roth individual retirement account or Roth individual
retirement annuity) or a designated Roth account in an employer plan (a tax-qualified plan or section 403(b)
plan) that will accept the rollover. The rules of the Roth IRA or employer plan that holds the rollover will
determine your investment options, fees, and rights to payment from the Roth IRA or employer plan (for
example, no spousal consent rules apply to Roth IRAs and Roth IRAs may not provide loans). Further, the
amount ro
lled over will become subject to the tax rules that apply to the Roth IRA or the designated Roth
account in the employer plan. In general, these tax rules are similar to those described elsewhere in this
notice, but differences include:
• If you do a rollover to a Roth IRA, all of your Roth IRAs will be considered for purposes of
3
determining whether you have satisfied the 5-year rule (counting from January 1 of the year for
which your first contribution was made to any of your Roth IRAs).
• If you do a rollover to a Roth IRA, you will not be required to take a distribution from the Roth IRA
during your lifetime and you must keep track of the aggregate amount of the after-tax contributions
in all of your
Rot
h IRAs (in order to determine your taxable income for later Roth IRA payments that
are not qualified distributions).
• Eligible rollove
r distributions from a Roth IRA can only be rolled over to another Roth IRA.
How do I do a rollover?
There are two ways to do a rollover. You can do either a direct rollover or a 60-day rollover.
If you do a direct rollover, the Plan will make the payment directly to your IRA, Roth IRA or an employer
plan. You should contact the IRA sponsor, Roth IRA sponsor (for designate Roth account) or the
administrator of the employer plan for information on how to do a direct rollover.
If you do not do a direct rollover, you may still do a rollover by making a deposit into an IRA, Roth IRA or
eligible employer plan that will accept it. You will have 60 days after you receive the payment to make the
deposit.
Non-designated Roth Account
If you do not do a direct rollover, the Plan is required to withhold 20% of the payment for federal income
taxes (up to the amount of cash and property received other than employer stock). This means that, in
order to roll over the entire payment in a 60-day rollover, you must use other funds to make up for the 20%
withheld. If you do not roll over the entire amount of the payment, the portion not rolled over will be taxed
and will be subject to the 10% additional income tax on early distributions if you are under age 59½ (unless
an exception applies).
Designated Roth Account
You can do a rollover by making a deposit within 60 days into a designated Roth account in an employer
plan if the payment is a nonqualified distribution and the rollover does not exceed the amount of the
earnings in the payment. You cannot do a 60-day rollover to an employer plan of any part of a qualified
distribution. If you receive a distribution that is a nonqualified distribution and you do not roll over an amount
at least equal to the earnings allocable to the distribution, you will be taxed on the amount of those earnings
not rolled over,
including the 10% additional income tax on early distributions if you are under age 59½
(unless an exception applies).
If you do a direct rollover of only a portion of the amount paid from the Plan and a portion is paid to you at
the same time, the portion directly rolled over consists first of earnings.
If you do not do a direct rollover and the payment is not a qualified distribution, the Plan is required to
withhold 20% of the earnings for federal income taxes (up to the amount of cash and property received
other than employer stock). This means that, in order to roll over the entire payment in a 60-day rollover to
a Roth IRA, you must use other funds to make up for the 20% withheld.
How much may I roll over?
If you wish to do a rollover, you may roll over all or part of the amount eligible for rollover. Any payment
from the Plan is eligible for rollover, except:
•
Certain payments spread over a period of at least 10 years or over your life or life expec
tancy (or
the lives or joint life expectancy of you and your beneficiary)
•
Required minimum distributions after age 70½ (if you were born before July 1, 1949) or age 72
(if you were born after June 30, 1949) or after death
4
• Hardship distributions
• ESOP dividends
• Corrective distributions of contributions that exceed tax law limitations
• Loans treated as deemed distributions (for example, loans in default due to missed payments
before your employment ends)
• Cost of life insurance paid by the Plan
• Payments of certain automatic enrollment contributions requested to be withdrawn within 90 days
of the first contribution
• Amounts treated as distributed because of a prohibited allocation of S corporation stock under an
ESOP (also, there will generally
be adverse tax consequences if you roll over a distribution of S
corporation stock to an IRA).
The Plan administrator or the payor can tell you what portion of a payment is eligible for rollover.
If I don’t do a rollover, will I have to pay the 10% additional income tax on early distributions?
If you are under age 59½, or the payment is not a qualified distribution from a designated Roth account,
you will have to pay the 10% additional income tax on early distributions for any payment from the Plan
(including amounts withheld for income tax) that you do not roll over, unless one of the exceptions listed
below applies. If the payment is from a designated Roth Account, you will have to pay the 10% additional
income tax only on the earnings allocated to the payment. This tax i
s in addition to the regular income ta
x
on the payment not rolled over.
The 10% additional income tax does not apply to the following payments from the Plan:
• Payments made after you separate from service if you will be at least age
55 n the year of the separation
• Payments that start after you separate from service if paid at least annually in equal or close to
equal amounts over your life or life expectancy (or the lives or joint life expectancy of you and your
beneficiary)
• Payments from a governmental defined benefit pension plan made after you separate from service
if you are a public safety employee and you are at least age 50 in the year of the separation
• Payments made d
ue to disability
• Payments after your death
• Payments of ESOP dividends
• Corrective distributions of contributions that exceed tax law limitations
• Cost of life insurance paid by the Plan
• Payments made directly to the government to satisfy a federal tax levy
• Payments made under a qualified domestic relations order (QDRO)
• Payments up to the amount of your deductible medical expenses
• Certain
payments made while you are on active duty if you were a member of a reserve component
called to duty after September 11, 2001 for more than 179 days
•
Payments of certain automatic enrollment contributions requested to be withdrawn within 90
days of the first contribution
If I do a rollover to an IRA, will the 10% additional income tax apply to early distributions from the
IRA?
If you receive a payment from an IRA when you are under age 59½, you will have to pay the 10% additional
income tax on early distributions from the IRA, unless an exception applies. In general, the exceptions to
the 10% additional income tax for early distributions from an IRA are the same as the exceptions listed
Payments of up to $5,000 made to you from a defined contribution plan within one year after the
birth or adoption of a child
•
5
above for early distributions from a plan. However, there are a few differences for payments from an IRA,
including:
• There is no exception for payments after separation from service that are made after age 55.
• The exception for qualified domestic relations orders (QDROs) does not apply (although a specia
l
rule a
pplies under which, as part of a divorce or separation agreement, a tax-free transfer may be
made directly to an IRA of a spouse or former spouse).
• The exception for payments made at least annually in equal or close to equal amounts over
a
s
pecified period applies without regard to whether you have had a separation from service.
• There are ad
ditional exceptions for (1) payments for qualified higher education expenses, (2)
payments up to $10,000 used in a qualified first time home purchase, and (3) payments for health
insurance premiums after you have received unemployment compensation for 12 consecutiv
e
wee
ks (or would have been eligible to receive unemployment compensation but for self-employed
status).
If I do a rollover to a Roth IRA, will the 10% additional income tax apply to early distributions from
the IRA?
If you receive a payment from a Roth IRA when you are under age 59½, you will have to pay the 10%
additional income tax on early distributions on the earnings paid from the Roth IRA, unless an exception
applies or the payment is a qualified distribution. In general, the exceptions to the 10% additional income
tax for early distributions from a Roth IRA listed above are the same as the exceptions for early distributions
from a plan. However, there are a few differences for payments f
rom a Roth IRA, inc
luding:
• Ther
e is no special exception for payments after separation from service.
• The exception for qualified domestic relations orders (QDROs) does not apply (although a specia
l
rule a
pplies under which, as part of a divorce or separation agreement, a tax-free transfer may
be
made directly to a Roth IRA of a spouse or former spouse).
Will I owe State income taxes?
This notice does not describe any State or local income tax rules (including withholding rules).
SPECIAL RULES AND OPTIONS
If your payment includes after-tax contributions, but is not a designated Roth account
After-tax contributions included in a payment are not taxed. If a payment is only part of your benefit, an
allocable portion of your after-tax contributions is included in the payment, so you cannot take a payment
of only after-tax contributions. However, if you have pre-1987 after-tax contributions maintained in a
separate account, a special rule may apply to determine whether the after-tax contributions are included
in a payment. In addition, special rules apply when you do a rollover, as described below.
You may roll over to an IRA a payment that includes after-tax contributions through either a direct rollover
or a 60-day rollover. You must keep track of the aggregate amount of the after-tax contributions in all of
your IRAs (in order to determine your taxable income for later payments from the IRAs). If you do a direct
rollover of only a portion of the amount paid from the Plan and at the same time the rest is paid to you, the
portion directly rolled over consists first
of the amount that would be taxable if not ro
lled over. For example,
assume you are receiving a distribution of $12,000, of which $2,000 is after-tax contributions. In this case,
if you directly roll over $10,000 to an IRA that is not a Roth IRA, no amount is taxable because the $2,000
amount not directly rolled over is treated as being after-tax contributions. If you do a direct rollover of the
entire amount paid from the Plan to two or more destinations at the same time, you can choose
whic
h
destination receives the after-tax contributions.
6
If you do a 60-day rollover to an IRA of only a portion of a payment made to you, the after-tax contributions
are treated as rolled over last. For example, assume you are receiving a distribution of $12,000, of which
$2,000 is after-tax contributions, and no part of the distribution is directly rolled over. In this case, if you roll
over $10,000 to an IRA that is not a Roth IRA in a 60-day rollover, no amount is taxable because the
$2,000 amount not rolled over is treated as being after-tax contributions.
You may roll over to an employer plan all of a payment that includes after-tax contributions, but only through
a direct rollover (and only if the receiving plan separately accounts for after-tax contributions and is not a
governmental section 457(b) plan). You can do a 60-day rollover to an employer plan of part of a payment
that includes after-tax contributions, but only up to the amount of the payment that would be taxable if not
rolled over.
If you miss the 60-day rollover deadline
Generally, the 60-day rollover deadline cannot be extended. However, the IRS has the limited authority to
waive the deadline under certain extraordinary circumstances, such as when external events prevented
you from completing the rollover by the 60-day rollover deadline. To apply for a waiver, you must file a
private letter ruling request with the IRS. Private letter ruling requests require the payment of a
nonrefundable user fee. For more information, see IRS Publication 590-A, Contributions to I
ndividua
l
Retirement Arrangements (IRAs).
If your payment includes employer stock that you do not roll over
If you do not do a rollover, you can apply a special rule to payments of employer stock (or other employer
securities) that are either attributable to after-tax contributions or paid in a lump sum after separation from
service (or after age 59½, disability, or the participant’s death). Under the special rule, the net unrealized
appreciation on the stock will not be taxed when distributed from the Plan and will be taxed at capital gain
rates when you sell the stock. Net unrealized appreci
ation is
generally the increase in the value of employer
stock after it was acquired by the Plan. If you do a rollover for a payment that includes employer stock (for
example, by selling the stock and rolling over the proceeds within 60 days of the payment), the special rule
relating to the distributed employer stock will not apply to any subsequent payments from the IRA or
employer plan. The Plan administrator can tell you the amount of any net unrealized appreciation.
Designated Roth Account
If you receive a payment that is not a qualified distribution and you do not roll it over, you can apply a
special rule to payments of employer stock (or other employer securities) that are paid in a lump sum after
separation from service (or after age 59½, disability, or the participant’s death). Under the special rule, the
net unrealized appreciation on the stock included in the earnings in the payment will not be taxed when
distributed to you from the Plan and will be taxed at capital gain rates when you sell the stock. If you do a
ro
llover to a Roth IRA for a nonqualified distribution that includes employer stock (for example, by selling
the s
tock and rolling over the proceeds within 60 days of the distribution), you will not have any taxable
income and the special rule relating to the distributed employer stock will not apply to any subsequent
payments from the Roth IRA or employer plan. Net unrealized appreciation is generally the increase in the
value of the employer stock after it was acquired by the Plan. The Plan administrator can tell you the
amount of any net unrealized appreciation. If you receive a payment
tha
t is a qualified distribution that
includes employer stock and you do not roll it over, your basis in the stock (used to determine gain or loss
when you later sell the stock) will equal the fair market value of the stock at the time of the payment from
the Plan.
If you have an outstanding loan that is being offset
If you have an outstanding loan from the Plan, your Plan benefit may be offset by the amount of the loan,
7
typically when your employment ends. The loan offset amount is treated as a distribution to you at the time
of the offset and will be taxed (including the 10% additional income tax on early distributions, unless an
exception applies) unless you do a 60-day rollover in the amount of the loan offset to an IRA or employer
plan.
Designate Roth Account
The loan offset amount is treated as a distribution to you at the time of the offset and, if the distribution is
a nonqualified distribution, the earnings in the loan offset will be taxed (including the 10% additional income
tax on early distributions, unless an exception applies) unless you do a 60-day rollover in the amount of
the earnings in the loan offset to a Roth IRA or designated Roth account in an employer plan.
If you were born on or before January 1, 1936
If you were born on or before January 1, 1936 and receive a lump sum Distribution (that is not a qualified
distribution from a designated Roth account) that you do not roll over, special rules for calculating the
amount of the tax on the payment might apply to you. For more information, see IRS Publication 575,
Pension and Annuity Income.
If your payment is from a governmental section 457(b) plan
If the Plan is a governmental section 457(b) plan, the same rules described elsewhere in this notice
generally apply, allowing you to roll over the payment to an IRA or an employer plan that accepts rollovers.
One difference is that, if you do not do a rollover, you will not have to pay the 10% additional income tax
on early distributions from the Plan even if you are under age 59½ (unless the payment is from a separate
account holding rollover contributions that were made to the Plan from
a tax-qualified p
lan, a section 403(b)
plan, or an IRA). However, if you do a rollover to an IRA or to an employer plan that is not a governmental
section 457(b) plan, a later distribution made before age 59½ will be subject to the 10% additional income
tax on early distributions (unless an exception applies). Other differences are that you cannot do a rollover
if the payment is due to an “unforeseeable emergency” and the special rules under “If your payment
includes employer stock that you do not roll over” and “If you
wer
e born on or before January 1, 1936” do
not apply.
If you are an eligible retired public safety officer and your pension payment is used to pay for health
coverage or qualified long-term care insurance
If the Plan is a governmental plan, you retired as a public safety officer, and your retirement was by reason
of disability or was after normal retirement age, you can exclude from your taxable income plan payments
or (nonqualified distributions from a designated Roth account) paid directly as premiums to an accident or
health plan (or a qualified long-term care insurance contract) that your employer maintains for you, your
spouse, or your dependents, up to a maximum of $3,000
annual
ly. For this purpose, a public safety officer
is a law enforcement officer, firefighter, chaplain, or member of a rescue squad or ambulance crew.
If you roll over your payment to a Roth IRA from an account that is not a designated Roth Account
If you roll over a non-Roth payment from the Plan to a Roth IRA, a special rule applies under which the
amount of the payment rolled over (reduced by any after-tax amounts) will be taxed. However, the 10%
additional income tax on early distributions will not apply (unless you take the amount rolled over out of
the Roth IRA within 5 years, counting from January 1 of the year of the rollover). If you roll over the payment
to a Roth IRA, later payments from the Roth IRA that are qualif
ied distributions wil
l not be taxed (including
earnings after the rollover). A qualified distribution from a Roth IRA is a payment made after you are age
59½ (or after your death or disability, or as a qualified first-time homebuyer distribution of up to $10,000)
and after you have had a Roth IRA for at least 5 years. In applying this 5-year rule, you count from January
1 of the year for which your first contribution was made to a Roth IRA. Payments from the Roth IRA that
8
are not qualified distributions will be taxed to the extent of earnings after the rollover, including the 10%
additional income tax on early distributions (unless an exception applies). You do not have to take required
minimum distributions from a Roth IRA during your lifetime. For more information, see IRS Publication 590-
A, Contributions to Individual Retirement Arrangements (IRAs), and IRS Publication 590-B, Distributions
from Individual Retirement Arrangements (IRAs).
If in-plan Roth Conversions are permitted (a rollover from a non-Roth account to a designated Roth
account in the Plan)
You cannot roll over a distribution to a designated Roth account in another employer’s plan. However, you
can roll the distribution over into a designated Roth account in the distributing Plan. If you roll over a
payment from the Plan to a designated Roth account in the Plan, the amount of the payment rolled over
(reduced by any after-tax amounts directly rolled over) will be taxed. However, the 10% additional tax on
early distributions will not apply (unless you take the amount rolled over out of the design
ated Roth account
within the 5-year period that begins on Jan
uary 1 of the year of the rollover).
If you roll over the payment to a designated Roth account in the Plan, later payments from the designated
Roth account that are qualified distributions will not be taxed (including earnings after the rollover). A
qualified distribution from a designated Roth account is a payment made both after you are age 59½ (or
after your death or disability) and after you have had a designated Roth account in the Plan for at least 5
years. In applying this 5-year rule, you count from January 1
of the year your first co
ntribution was made
to the designated Roth account. However, if you made a direct rollover to a designated Roth account in
the Plan from a designated Roth account in a plan of another employer, the 5-year period begins on
January 1 of the year you made the first contribution to the designated Roth account in the Plan or, if
earlier, to the designated Roth account in the plan of the other employer. Payments from the designated
Roth account that are not qual
ified distribut
ions will be taxed to the extent of earnings after the rollover,
including the 10% additional income tax on early distributions (unless an exception applies).
If you are not a plan participant
Payments after death of the participant. If you receive a distribution after the participant’s death that you
do not roll over, the distribution will generally be taxed in the same manner described elsewhere in this
notice. However, whether a designated Roth account payment is a qualified distribution generally depends
on when the participant first made a contribution to the designated Roth account in the Plan. Also, the
10% additional income tax on early distributions and the special rules for public safety officers do not apply,
and the special rule described under the section “If you were born
on or before January 1, 1936” applies
only if the participant was born on or before January 1, 1936.
If you are a surviving spouse. If you receive a payment from the Plan as the surviving spouse of a
deceased participant, you have the same rollover options that the participant would have had, as
described elsewhere in this notice. In addition, if you choose to do a rollover to an IRA, you may treat the
IRA as your own or as an inherited IRA. An IRA you treat as your own is treated like any other IRA of
yours, so that payments made to you before you are age 59½ will be subject to the 10% additional
income tax
on early distributions (unless an exception applies) and required minimum distributions from
your IRA do not have to start until after you are age 70½ (if you were born before July 1, 1949) or age
72 (if you were born after June 30, 1949). If you treat the IRA as an inherited IRA, payments from the
IRA will not be subject to the 10% additional income tax on early distributions. However, if the participant
had started taking required minimum distributions, you will have to receive required minimum
distributions from the inherited IRA. If the participant had not started taking required minimum
distributions from the Plan, you will not have to start receiving required minimum distributions from the
inherited IRA until the year the participant would have been age 70½ (if you were born before July 1,
1949) or age 72 (if you were born after June 30, 1949).
Designated Roth Account
If you choose to do a rollover to a Roth IRA, you may treat the Roth IRA as your own or as an inherited
9
Roth IRA. A Roth IRA you treat as your own is treated like any other Roth IRA of yours, so that you will not
have to receive any required minimum distributions during your lifetime and earnings paid to you in a
nonqualified distribution before you are age 59½ will be subject to the 10% additional income tax on early
distributions (unless an exception applies). If you treat the Roth IRA as an inherited Roth IRA, payments
from the Roth IRA will not be subject to the 10% additional income tax on early di
stributions. An inherited
Roth IRA is subject to required minimum distributions. If the participant had started taking required
minimum distributions from the Plan, you will have to receive required minimum distributions from the
inherited Roth IRA. If the participant had not started taking required minimum distributions, you will not
have to start receiving required minimum distributions from the inherited Roth IRA until the year the
participant would have been age 70½ (if you were born before July 1, 1949) or age 72 (if you were born
after June 30, 1949).
If you are a surviving beneficiary other than a spouse. If you receive a payment from the Plan
because of the participant’s death and you are a designated beneficiary other than a surviving
spouse, the only rollover option you have is to do a direct rollover to an inherited IRA or Roth IRA
(for designated Roth accounts). Payments from the inherited IRA or Roth IRA will not be subject to the
10% additional income tax on early distributions. You will have to receive required minimum
distributions from the inherited IRA or Roth IRA.
Payments under a qualified domestic relations order. If you are the spouse or former spouse of the
participant who receives a payment from the Plan under a qualified domestic relations order (QDRO), you
generally have the same options the participant would have (for example, you may roll over the payment
to your own IRA or an eligible employer plan that will accept it). Payments under the QDRO will not be
subject to the 10% additional income tax on early distributions.
If you are a nonresident alien
If you are a nonresident alien and you do not do a direct rollover to a U.S. IRA or U.S. employer plan,
instead of withholding 20%, the Plan is generally required to withhold 30% of the payment for federal
income taxes. If the amount withheld exceeds the amount of tax you owe (as may happen if you do a 60-
day rollover), you may request an income tax refund by filing Form 1040NR and attaching your
Form 1042-S. See Form W-8BEN for claiming that you are entitled to a reduced rate of withholding under
an income tax treaty. For more information, see also IRS Publication 519, U.S. Tax Guide for Aliens, and
IRS Publication
515, Withholding of Tax on Nonresident Aliens and Foreign Entities.
Other special rules
If a payment is one in a series of payments for less than 10 years, your choice whether to make a direct
rollover will apply to all later payments in the series (unless you make a different choice for later payments).
If your payments for the year are less than $200 (not including payments from a designated Roth account
in the Plan), or your payments from the designated Roth account is less than $200, the Plan is not required
to allow you to do a direct rollover and is not required to withhold for federal income taxes. However, you
may do a 60-day rollover.
Unless you elect otherwise, a mandatory cashout of more than $1,000 (not including payments from a
designated Roth account in the Plan) will be directly rolled over to an IRA chosen by the Plan administrator
or the payor. A mandatory cashout is a payment from a plan to a participant made before age 62 (or normal
retirement age, if later) and without consent, where the participant’s benefit does not exceed $5,000 (not
including any amounts held under the plan as a result of a prior
rollover mad
e to the plan).
You may have special rollover rights if you recently served in the U.S. Armed Forces. For more information,
see IRS Publication 3, Armed Forces’ Tax Guide.
10
FOR MORE INFORMATION
You may wish to consult with the Plan administrator or payor, or a professional tax advisor, before taking
a payment from the Plan. Also, you can find more detailed information on the federal tax treatment of
payments from employer plans in: IRS Publication 575, Pension and Annuity Income; IRS Publication 590-
A, Contributions to Individual Retirement Arrangements (IRAs); IRS Publication 590-B, Distributions from
Individual Retirement Arrangements (IRAs); and IRS Publication 571, Tax-Sheltered Annuity Plans
(403(b)
Plans). These publications are available from a local IRS office, on the web at
www.irs.gov, or by calling
1-800-TAX-FORM.
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457(b) Plan Transaction Request Form

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Completed 2 August 2020

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