Fill - Free fillable Application For Withdrawal PDF form

The Application for Withdrawal of Total Accumulated Deductions allows an eligible member to

receive a refund of the total accumulated deductions in his or her annuity savings (retirement)

account. An eligible member is one who:

 has terminated his or her employment with a governmental unit;

 is not receiving workers’ compensation;

 is not seeking to be restored to his or her position; and

 is not accepting a position in the service of the Commonwealth or one of

its political subdivisions.

Members are strongly advised to review the following:

 If you have over ten years of creditable service, you may currently be or

might become eligible for a retirement allowance. By taking a withdrawal

of your accumulated total deductions, you will lose any right to this

retirement allowance. Before proceeding with a withdrawal, you should

ask your retirement board for a personalized estimate of any benefits that

you will forego by withdrawing.

 Taking a refund of your total accumulated deductions terminates your

rights in the retirement system and may subject you to tax consequences.

For distributions made after January 1, 2002, please be aware that your

options of an eligible retirement plan for transferring your deductions have

been expanded dramatically. Please carefully review the “Special Tax

Notice” that accompanies this application. If you have unresolved

concerns, you may wish to consult with an attorney or a tax professional.

 The amount of interest that members receive will vary, depending upon the years of

creditable service and the nature of the separation from employment.

 Your employer must certify the termination of your employment, that you owe no

obligation to the employer under an employee benefit plan, and sign this application.

 Your retirement board will determine if you are eligible for a refund of your

total accumulated deductions.

Instructions

Members must complete pages 1, 2, and 3, and sign page 3.

Introduction

Application for Withdrawal of Accumulated Total Deductions

Form Last Revised: June, 2011

COMMONWEALTH OF MASSACHUSETTS | PUBLIC EMPLOYEE RETIREMENT ADMINISTRATION COMMISSION

WEB | WWW.MASS.GOV/PERAC

Application for Withdrawal of Accumulated Total Deductions

Form Last Revised: June, 2011

To the Retirement Board Date

Section A: To Be Completed by the Member

Name (Print) Social Security # Phone #

Former or Maiden Name (if different) Cell Phone # E-mail Address

I (Check One) terminated resigned from my position, (job title) with the

political subdivision of , effective .

I, the undersigned, hereby request that the amount in my Annuity Savings Fund account be paid to me as

directed herein. I understand that in consideration of the return of said amount, my membership in the

Retirement System shall terminate and all rights and privileges to which I was entitled as a member of the

Retirement System are hereby surrendered, including eligibility for a termination retirement allowance upon

completion of 20 years of service and including eligibility to receive a retirement allowance upon completion

of 10 years of service and upon attaining age 55. I hereby elect to receive a return of my accumulated total

deductions as provided herein in lieu of the receipt of such allowance. I understand that if I return to employ-

ment that renders me eligible to become a member of a Retirement System, I will do so with the status of a

new member with the contribution rate then in effect and will not be entitled to creditable service for my

previous service unless after I return to service and before the date that any retirement allowance becomes

effective for me I pay into the Annuity Savings Fund of the Retirement System an amount equal to the accu-

mulated deductions withdrawn by me together with buyback interest to date. Such payment into the Annuity

Savings Fund of the Retirement System shall be in one lump sum or in installments as authorized by the

Retirement Board. I understand that the Retirement Board will provide my name to the Massachusetts

Department of Revenue for child support obligation purposes.

I have read the Special Tax Notice Regarding Plan Payments provided to me by the Retirement Board. I

understand that if I choose to directly receive the return of my accumulated total deductions, 20% of the

taxable portion of such return will be withheld and paid to the Internal Revenue Service.

1) It is it is not my intention to accept a position in the service of the Commonwealth or any

political subdivision thereof which would entitle me to become a member of any similar contributory

retirement system or seek to be restored to the position from which I was terminated.

2) I am I am not receiving Workers’ Compensation Benefits pursuant to the provisions of

G.L. c. 152.

Retirement

Board: Please

place your address

and phone

number here. 

COMMONWEALTH OF MASSACHUSETTS | PUBLIC EMPLOYEE RETIREMENT ADMINISTRATION COMMISSION

WEB | WWW.MASS.GOV/PERAC

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3) Have you been officially investigated for or charged with misappropriation of funds from your

employer or convicted of any crime related to your office or position? Yes No

If yes, please provide documentation.

Method of Payment

4) Check One:

A) I wish to have the amount of my Annuity Savings Fund that is eligible for a refund paid directly to me

in full with the exception of the 20% withholding of the federally taxable portion, which will be paid to

the Internal Revenue Service.

B) I wish to have the federally taxable amount of my Annuity Savings Fund that is eligible for a refund

paid directly to an IRA, a 401(a) qualified plan, a 403(b) annuity contract, or an eligible governmental

457(b) deferred compensation plan as specified below, with the federally non-taxable amount paid

directly to me.

C) I wish to have the federally non-taxable amount of my Annuity Savings Fund paid to an IRA or a 401(a)

defined contribution plan as specified below, with the federally taxable amount paid directly to me.

D) I wish to have the federally taxable amount of my Annuity Savings Fund that is eligible for a refund

paid directly to an IRA, a 401(a) qualified plan, a 403(b) annuity contract, or an eligible governmental

457(b) deferred compensation plan as specified below, with the federally non-taxable amount of my

Annuity Savings Fund paid to an IRA or a 401(a) qualified defined contribution plan as specified below.

E) I wish to have ______% of the federally taxable amount of my Annuity Savings Fund that is eligible for a

refund paid directly to me (on which I realize there will be 20% withholding paid to the Internal Revenue

Service) and the balance of the federally taxable amount of my Annuity Savings Fund paid directly to

an IRA, a 401(a) qualified plan, a 403(b) annuity contract, or an eligible governmental 457(b) deferred

compensation plan as specified below, with the federally non-taxable amount paid directly to me.

For Taxable Portion

Application for Withdrawal of Accumulated Total Deductions 2

Member’s Last Name First M.I. Social Security #

- -

Name (IRA, qualified 401(a) plan, 403(b) annuity provider, or eligible governmental 457(b) deferred

compensation plan)

Address of above-listed entity City State Zip

Member’s Account Number with above-listed entity

Member’s Address City State Zip

For Non-Taxable Portion

Section B: To Be Completed by the Department Head

This is to notify the Retirement Board that was (job title)

in the department in the political subdivision of who

(Check One) resigned terminated on and that the above named employee will appear

on the payroll for the last time on the pay period ending .

1) To the best of my knowledge the above named employee is not leaving to accept a position in the ser-

vice of the Commonwealth or any political subdivision thereof which would entitle the above to

become a member of any similar contributory retirement system and is not seeking to be restored to

the position from which such employee was terminated.

2) Was the above member employed less than full time? Yes No

3) Is the above employee receiving Workers’ Compensation benefits? Yes No

4) Does the above employee owe any money to the employer under an employee benefit plan, including

a cafeteria plan established pursuant to 26 U.S.C. section 125? Yes No

5) Has this employee been officially investigated for or charged with misappropriation

of funds from his/her employer or convicted of any crime related to his/her office

or position? Yes No

If yes, please provide documentation.

Signature/Department Head _________________________________________________

Name (IRA, qualified 401(a) defined contribution plan)

Address of above-listed entity City State Zip

Member’s Account Number with above-listed entity

Member’s Address City State Zip

Member & Witness Signature Block

I request payment according to the method selected on page 2.

Member’s Signature ____________________________________ Date of Signature___________

Witness’ Signature _____________________________________

Witness’ Printed Name____________________________________ Date of Signature___________

Application for Withdrawal of Accumulated Total Deductions 3

Member’s Last Name First M.I. Social Security #

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Section C: To Be Completed by the Retirement Board

Determination of Eligibility for Return of Accumulated Total Deductions

Members are eligible for a refund of accumulated total deductions under the following conditions.

Check the condition which applies to this member.

1) The member is leaving service and does not intend to take a position in the service of the

Commonwealth or any political subdivision thereof subject to the provisions of G.L. c. 32, §§ 1-28 and

does not intend to seek to be restored to the position from which he/she was terminated.

2) The member is leaving service as above and is otherwise entitled to receive a retirement allowance

but the normal yearly amount of the allowance would be less than $360, the member MUST receive a

refund.

3) The member is a veteran who entered the service of a governmental unit within the Commonwealth

prior to July 1, 1939 and is retiring under G.L. c. 32, §§ 56-60. (Under this condition the member must

sign the waiver on the appropriate form).

4) In general, if a member is employed by two or more governmental units and enrolled in the retire-

ment systems pertaining to each governmental unit, upon ending service in one unit, the member’s

accumulated total deductions must be transferred to the retirement system pertaining to the unit in

which service continues. However, if the member has contributed a lesser amount to the Annuity

Savings Fund of the system in which service has ended, the member is entitled to a refund of those

accumulated total deductions.

NOTE: The right to receive a retirement allowance or a return of accumulated total deductions is subject

to the provisions of G.L. c. 32, § 15 pertaining to dereliction of duty by members and G.L. c. 32, § 19C

pertaining to child support obligations.

Years and Months of Creditable Service

Interest Provisions

No interest shall be included in the accumulated total deductions paid to the member for any period after the

expiration of two years from the end of the month preceding the date of his or her termination of service.

Members who entered into service on or after January 1, 1984 are subject to the following provisions with

respect to the refund of interest credited to their annuity accounts.

Check the condition which applies to this member:

1) The member has less than 120 months (10 years) of creditable service and has voluntarily withdrawn

from service. The member will receive 3% interest on accumulated total deductions.

Application for Withdrawal of Accumulated Total Deductions 4

Member’s Last Name First M.I. Social Security #

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2) The member has more than 120 months (10 Years) of creditable service and has voluntarily with-

drawn from service. The member will receive 100% interest of the regular interest on accumulated

total deductions.

3) The member was involuntarily terminated from service. The member will receive 100% of the regular

interest on accumulated total deductions, regardless of his or her amount of creditable service.

Refund

Total in annuity savings account as of date of withdrawal $

Minus interest not eligible for refund $

*

TOTAL REFUND TO BE ISSUED

Federal taxable portion $ Federal non-taxable portion $

AMOUNT REFUNDED (Fill in those that apply)

To Member $

To Department of Revenue/

Child Support Enforcement Unit $

To Designated Plan (IRA, 401(a), $ Type of Plan

403(b), 457.)

To Internal Revenue Service $

To Pension Reserve Fund $

To Retirement System $

Date of Retirement Board vote authorizing refund

Date refund issued

Signature ________________________________________

Board Member or Administrator

Print Name

*Note: No regular interest shall be included in the amount of any accumulated total deductions which are to

be paid to the member for any period after the expiration of two years from the end of the month immedi-

ately preceding the date of his termination of service.

Application for Withdrawal of Accumulated Total Deductions 5

Member’s Last Name First M.I. Social Security #

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