Fillable APPLICATION FOR SERVICE RETIREMENT (Virginia Retirement System)

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APPLICATION FOR SERVICE RETIREMENT (Virginia Retirement System)

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VRS-5 (Rev. 08/20)

*VRS-000005*

APPLICATION FOR SERVICE RETIREMENT

PART A. MEMBER INFORMATION

4. Name

(First, Middle Initial, Last)

5. Address (Street, City, State and ZIP+4)

6. Are you a Virginia resident?

 Yes  No

7. U.S. Citizenship

 U.S. Citizen  Resident Alien

 Non-resident Alien (Marking this box certifies your status as non-resident

alien and that you are not a U.S. citizen or resident alien.)

8. Marital Status for Retirement Purposes

 N

ever Married  Married or Separated  Widowed  Divorced – Date of Divorce

(mm/dd/yyyy)

9. Phone Number

10. Birth Date (mm/dd/yyyy) 11. Email Address

12. Do you intend to make a lump-sum purchase of service credit prior to retirement?  Yes  No

13. Will you be purchasing service credit with a sick leave payment? (Irrevocable option)  Yes  No

14. VSDP Participants Only: Will you be converting disability credit to service credit when

you retire? (Irrevocable option)

 Yes  No

15. Will you be terminating all full-time and part-time employment eligible for coverage under

VRS

, including employment covered by an optional retirement plan, as well as terminating

any part-time employment not eligible for coverage under VRS with the employer from

which you are retiring as of your retirement date? (See instructions for more information)

 Y

es  No

1. Social Security Number

2. Retirement Date (Enter month and year)

/ 01 /

3. Check One

 Original Application



Revised Application

VIRGINIA RETIREMENT SYSTEM

P.O. Box 2500



Richmond, VA 23218-2500

Toll-free 1-888-827-3847

Fax 804-786-9718

www.varetire.org

Clear Form

VRS-5 (Rev. 08/20)

PART B. PAYOUT OPTION SELECTION

17. Retirement Payout Option (Choose only one)

 Basic Benefit

 Basic Benefit with a Partial Lump-Sum Option

Payment (PLOP)



Survivor Option with % payable to survivor

 Survivor Option with % payable to survivor

and a Partial Lump-Sum Option Payment (PLOP)

 Advance Pension Option w/ as the age at which my benefit should decrease

18. If you selected an option including a PLOP payment, choose the number of months to be represented by the payment:

 12 months  24 months  36 months

Do you intend to roll the funds into an IRA or other qualified plan?  Yes  No

(Review the IRS 402(f) – Special Tax Notice at www.varetire.org/forms to learn about rollovers and direct payments)

PART C. SURVIVOR INFORMATION (Complete if payout option in Part B is a Survivor Option.)

Your survivor is the person to whom your monthly retirement benefit will continue upon your death. (This is different than

naming a beneficiary on the VRS-2.)

19. Survivor’s Name

(First, Middle Initial, Last)

20. Relationship

 Spouse  Other

21. Survivor’s Birth Date (mm/dd/yy)

22. Survivor’s SSN 23. Survivor’s Gender

 Male  Female

24. Survivor’s U.S. Citizenship

 U.S. Citizen  Resident Alien  Non-resident Alien (Marking this box certifies your status as non-resident

alien and that you are not a U.S. citizen or resident alien

PART D. CERTIFICATION

Member Certification

I hereby certify: 1) All information I provide in this document is true and I understand that any willful falsification of facts presented may

result in prosecution as provided by law, 2) I have read and understand the service retirement information in the Handbook for

Members, 3) I will terminate all full-time positions with VRS employers prior to my retirement and 4) I will not return to work in a part-

time position with my current employer following my retirement date for at least one full calendar month during which I would normally

work. Additionally, I agree that, in the event that VRS pays retirement benefits in excess of those to which I am entitled, I or my estate

will repay the excess to VRS. By signing this form, I hereby assign to VRS any VRS group life insurance benefits that may be payable

as a result of my death to secure repayment of any such retirement benefit overpayment.

If I selected a monthly benefit with a PLOP payment, my signature also certifies that: 1) I have reviewed and understand the IRS 402(f)

Special Tax Notice; 2) I understand a 20 percent federal tax is withheld from the taxable portion of the payment made to me and, if I

am a resident of Virginia, an additional four percent state tax is withheld; 3) I may be subject to an additional 10 percent federal tax

penalty on the taxable portion of the payment and 4) I confirm the payment(s) and/or rollover(s) as shown above.

I hereby authorize VRS to deposit my monthly retirement benefit payment directly to my account at the financial institution shown in

Part F. I agree to provide written notification to VRS within 30 days of any changes to this information so that my monthly benefit may

be properly distributed. I also authorize VRS to make adjustments to my account to correct any credit entries made in error.

Member Signature Date

Spouse Certification (Required if married or separated)

I have read and understand the retirement payout options available under VRS. I am aware of and understand the retirement payout

option selected by my spouse and if my spouse chose a Survivor Option, the survivor benefits will be provided to the person named in

Part C. Further, I am aware that counseling regarding the payout options is available.

Spouse’s Signature Date

16. SSN

VRS-5 (Rev. 08/20)

PART E. PLOP PAYMENT SELECTIONS

You may choose to have your PLOP payment paid to you or rolled over, or you may choose a combination of both. Funds

being paid directly to you will be deposited into the account you enter in Part F for your monthly benefit.

Make your selections below indicating the percentage of funds paid directly to you and the percentage to be rolled over. If

your rollover is being split between institutions, copy this page as needed to provide information for all accounts.

 Check this box if you do not have an account where we can deposit the portion of your PLOP payment being rolled

over, or if you are unsure how you want the funds paid.

(VRS will send you a letter by U.S. postal mail requesting this information when we are processing your retirement.

Please note, this may delay processing of your retirement and receipt of your PLOP payment.)

Non-taxable funds to be paid to you and/or rolled over:

________ % paid directly to me

+ ________ % paid to the institution accepting non-taxable

funds as a rollover

= ___100__

% Total non-taxable funds

Taxable funds to be paid to you and/or rolled over:

________ % paid directly to me

+ ________ % paid to the institution accepting taxable funds as a

rollover

= ___100 _

% Total taxable funds

If you elect to roll a portion of the non-taxable funds,

provide financial institution information below:

__________________________________________________

IRA Custodian/Employer Plan Trustee

__________________________________________________

Plan Name (State Employees Only)

Address

__________________________________________________

City/State/Zip

_______________________ ________________________

Account Number Phone Number

Type of Account (One Choice Required):

 IRA  Other Qualified Plan

 401(a)  401(k)  403(b)

Rollover Payment Delivery Options:

 Mail the check to me.

 Mail the check to my financial institution.

To the attention of:

If you elect to roll a portion of the taxable funds, provide

financial institution information below:

___________________________________________________

IRA Custodian/Employer Plan Trustee

___________________________________________________

Plan Name (State Employees Only)

Address

___________________________________________________

City/State/Zip

_________________________ _________________________

Account Number Phone Number

Type of Account (One Choice Required):

 IRA  Other Qualified Plan

 401(a)  401(k)  403(b)  457

Rollover Payment Delivery Options:

 Mail the check to me.

 Mail the check to my financial institution.

To the attention of:

25. SSN

VRS-5 (Rev. 08/20)

PART F. ACCOUNT FOR DIRECT DEPOSIT OF MONTHLY BENEFIT

Your monthly benefit is deposited into the account you identify below. Note: If you selected a payout option that includes a

PLOP payment, any PLOP funds being paid directly to you also are deposited in the account below.

27. Financial Institution Name 28. Account Type (Choose one)

 Checking  Savings

29. Financial Institution Account Information

Provide a voided check with the correct routing information and account number. To ensure the information you provide is

accurate, you may wish to contact your financial institution.

TAPE VOIDED CHECK WITHIN THE LINES OF THIS BOX

PART G. MONTHLY BENEFIT TAX WITHHOLDING

30. FEDERAL INCOME TAX WITHOLDING (Choose one option below)

 Do not withhold federal income tax from my monthly benefit. I understand I am liable for paying federal income

tax on the taxable portion of my benefit and I may be subject to tax penalties under the estimated tax payment

rules if my payment(s) of estimated tax and withholding are not adequate. (If I am a U.S. citizen or resident

alien whose benefit payments are delivered outside the U.S. or its possessions, I must have federal income tax

withheld.)

 Calculate my federal income tax withholding (if any) in accordance with the tax formula as published in IRS

Publication 15 based on the following selections:

Marital Status for Federal Taxes:  Single  Married

Number of

Allowances:

To withhold an amount in addition to the calculated tax, enter the amount per month: $

31. STATE OF VIRGINIA INCOME TAX WITHHOLDING (Choose one option below. You are not required to have Virginia state

income tax withheld from your benefit if you do not reside in Virginia.)

 Do not withhold state income tax from my monthly benefit. I understand I am liable for paying state income tax

on the taxable portion of my benefit and I may be subject to tax penalties under the estimated tax payment rules

if my payment(s) of estimated tax and withholding are not adequate.

 Calculate my state income tax withholding (if any) in accordance with the tax formula as published in the

Virginia Income Tax publication based on the following selections:

Marital Status for State Taxes:  Single  Married

Exemp

tions: Personal: Age and Blindness: Total:

To withhold an amount in addition to the calculated tax, enter the amount per month: $

26. SSN

VRS-5 (Rev. 08/20)

INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR SERVICE RETIREMENT

Please read the service retirement information in your Handbook for Members before completing your

application. You may obtain this handbook from your benefits administrator or view it on the VRS website

(www.varetire.org). Use myVRS on the VRS website to estimate your VRS benefits before applying for

retirement.

Submit your application to the Virginia Retirement System (VRS) at least 60 days, but not more than four

months, prior to your effective date of retirement. This ensures you will receive your first benefit payment the

first of the month following your retirement date.

When submitting your application:

• If you intend to purchase service credit with your sick leave payment or convert disability credit to service

credit, request your benefits administrator complete the necessary online certification. These options are

irrevocable and cannot be reversed.

• If you are on VSDP long-term disability, send the application directly to VRS for certification.

If all required documents are not received by VRS within 60 days of your anticipated retirement date,

processing of your application will be delayed. This will affect when your first benefit payment is made. VRS will

process your application within 60 days of the date all documents are received.

Considerations:

You must terminate all full-time and part-time positions that are covered by VRS to receive a monthly retirement

benefit. This includes positions which provide retirement benefits in any VRS administered Optional Retirement

Plan or a public college or university Optional Retirement Plan authorized by the Code of Virginia. At the time of

retirement, you must also terminate work in any part-time positions not covered under VRS for the employer

from which you are retiring.

If you return to work in a full-time or part-time position covered by VRS for retirement purposes, a VRS-

administered Optional Retirement Plan or a public college or university Optional Retirement Plan authorized by

the Code of Virginia, your monthly retirement benefit must cease.

If you plan to return to work in a part-time position with any employer participating in VRS, your employer must

comply with Internal Revenue Service (IRS) rules about in-service distributions. For your employer to be in

compliance, you must:

• Terminate all full-time and part-time employment with your current employer before you receive your benefit

payment.

• Incur a break in service of at least one full calendar month before returning to part-time employment in a

position not covered by VRS with your current employer. This break must occur during a normal work

period.

Note: State agencies are considered one employer. Retired state employees may return to work in part-time

positions with other state agencies after a full calendar month break in service during a normal work period

VRS-5 (Rev. 08/20)

Part A. Your Information

Box 1-11: Enter your personal information. In Box 2, indicate your retirement date by entering the month and

year.

Box 12: If you check yes, the purchase must be completed while actively employed and no later than your

date of termination. Your benefit cannot be calculated until payment for the purchase is submitted to

VRS.

Box 13: If you check yes, be sure your employer has completed the on-line certification for your

accumulated sick leave using myVRS Navigator.

Box 14: If you check yes, be sure your employer has completed the on-line certification for your conversion

of disability credits using myVRS Navigator.

Box 15: You must terminate all full-time and part-time positions that are covered by VRS, including positions

covered by an optional retirement plan, to receive a monthly retirement benefit. At the time of

retirement, you must also terminate work in any part-time positions not covered under VRS for the

employer from which you are retiring. Choose yes or no as appropriate.

Part B. Your Payout Option Selection

Box 17: Choose only one payout option. Refer to your Handbook for Members to determine which option

will meet your retirement goal. If you are considering the PLOP, refer to the IRS 402(f) Special Tax

Notice on the VRS website to learn more about the tax implications of a lump-sum payment.

If you select the Advance Pension Option, enter the age at which you want your temporarily

increased VRS benefit to be reduced. You must choose an age of at least 62 years, but no later

than your normal retirement age as defined by the Social Security Act. Note: You must include an

estimate from the online Social Security Administration benefit estimator following the instructions

on the VRS website at www.varetire.org/apo

. This estimate must be less than 12 months

old, for

the age at which you choose for your VRS benefit to decrease and it should assume no future

earnings after leaving your covered position. Additional information about this option will be sent

when your application is processed.

Box 18: If

your payout option includes a PLOP payment, indicate number of months on which the amount is

to be based. For a 12-month payment, you must work at least one year beyond the date you are

first eligible for an unreduced retirement benefit; for a 24-month payment, at least two years; and for

a 36-month payment, at least three years. Also indicate whether you intend to roll the PLOP funds

into an IRA or other qualified plan.

Part C. Your Survivor’s Information (Only if you chose a payout option including a survivor)

Enter your survivor’s information as identified on the form. (Do not complete this section if you chose the

Basic Benefit as your payout option.)

VRS-5 (Rev. 08/20)

Part D. Your Certification

Carefully read the certification statement. Sign and date the application. Your signature certifies that you will

repay benefits in excess of those to which you are entitled. It also certifies that you understand that you cannot

return to work in a part-time position working for the employer from which you retired without first incurring the

required break in service.

If you are unable to complete the application and you select a payout option other than the Basic Benefit, an

individual authorized to make testamentary changes on your behalf may complete your application. Authorized

individuals include: a court-appointed Guardian or Committee; an Attorney-in-Fact named in a Durable Power of

Attorney; or an individual specifically authorized by a court order to do so. A copy of the document providing

such authorization must be presented to VRS for review before the application can be processed. If the

application is not signed and dated, it is not valid and a new one must be completed. This may delay your first

payment.

If you checked Married or Separated in Part A, your spouse must complete the Spouse Certification section,

signing and dating the application on or after the date you sign; otherwise, a new application must be

completed. If you are unable to obtain your spouse’s signature, contact VRS for additional information.

Part E. Your Direct Deposit of PLOP Payment (Only if you chose a payout including a PLOP payment)

Of the total PLOP payment, you must select the percentage of any non-taxable and taxable funds to be paid to

you or rolled directly into another qualified plan. If you select to rollover any/all of your PLOP payment, complete

all information about the financial institution and your account. You may have the check sent directly to your

financial institution, and you may enter the name of the person who should receive the check, if it is required.

If you want all or a portion of the PLOP rolled over into a qualifying account, but you do not have the account

information when completing this application, check the box in Part E to indicate this. VRS will process your

retirement and send you another form to obtain the PLOP information.

Note: Your PLOP payment may be: 1) paid directly to you by direct deposit into the account where your

monthly benefit will be deposited or 2) paid in a rollover to a traditional individual retirement account (IRA) or

another eligible plan that accepts rollovers. A rollover into another eligible plan or IRA allows you to continue to

postpone taxation of the funds until they are paid to you. To learn more about the tax implications of your

selection, read the IRS 402(f) – Special Tax Notice – Defined Benefit Plans on the VRS website at

www.varetire.org/forms.

Part F. Your Direct Deposit Selections

Provide all information about the financial institution to which your monthly benefit will be paid.

Part G. Your Tax Withholding Selections

Select how to have both federal and state income taxes withheld from your monthly benefit. If you select to

withhold taxes for federal or state, also indicate marital status and select the number of allowances for any

taxes you choose to withhold. You also may enter an additional amount to be withheld each month in addition to

the calculated taxes.

IMPORTANT NOTE: VRS will notify your employer when your application is received. Your employer will certify

your separation from employment online.

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