Fillable Application for Refund of Accumulated Contributions Tennessee Consolidated (State of Tennessee)

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Application for Refund of Accumulated Contributions Tennessee Consolidated (State of Tennessee)

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RDA-413
Page 1 of 4
Application for
Refund of
Accumulated
Contributions
Tennessee Consolidated Retirement System
502 Deaderick Street
Nashville, Tennessee 37243-0201
1-800-770-8277 w http://tcrs.tn.gov
In order to qualify for a refund, a member must (1) have funds in TCRS, (2) no longer be employed
by any employer covered by TCRS and (3) complete this application and return it to TCRS at the
above address. Please read the income tax information beginning in Section 6 before completing your
application.
SECTION 1. MEMBER INFORMATION
Member ID Last 4 SSN XXX-XX- Date of Birth
Full Name
Mailing Address
City State Zip Code
Email Daytime Phone Number
Former TCRS Employer Date Employment Terminated
I understand that it is my responsibility to update my address if it changes during the processing of this refund.
I acknowledge that failure to report my address change will result in delays. The United States Postal Service
does not forward checks from TCRS. Digital signatures are not accepted.
I hereby make application for the return of my contributions made to the Tennessee Consolidated Retirement
System (TCRS) together with the interest credited thereon. I hereby waive for myself, my heirs and my beneciary
all my rights, title and interest in all funds under the care and control of the retirement system. This includes
eligibility to participate in the State Insurance Plan. I understand that this election is irrevocable.
I am aware that if I DO NOT withdraw my contributions, and not having acquired vesting rights, I will retain my
status as a member of the retirement system for seven years, and should I be reemployed within that period,
I will retain my status as a member of the retirement system, or having attained vesting rights, I may remain a
member and elect to receive a monthly retirement benet at retirement age. I understand that if I DO withdraw
my contributions, my membership in the retirement system is terminated and, if I am subsequently employed in
a position requiring membership, I must enter the retirement system with the status of a new member.
Date
Member’s Signature
Digital Signatures will not be accepted
TR-0026 (Rev. 6/2020)
TR-0026 (Rev. 6/2020) RDA-413
Page 2 of 3
SECTION 2. WITHHOLDING ON REFUNDS/DIRECT TRANSFER TO ANOTHER RETIREMENT
PLAN
All refunds issued directly to former members of TCRS are subject to federal income tax withholding
at a rate of 20% of the taxable portion of the refund. However, the taxable portion of the refund may
be transferred directly from TCRS to another retirement plan, with the nontaxable portion (if any
exists) being refunded directly to you. If you choose to have the taxable portion transferred directly to
another retirement plan, the distribution will not be taxable and federal income tax will not be withheld.
Because my refund may constitute an eligible rollover distribution under federal tax law, I understand I have
at least 30 days before distribution to consider the information provided in this Refund Application and decide
whether to elect a direct rollover to another qualied plan with a nancial institution or have the amount distributed
directly to me. By submitting this Refund Application, I arm the 30 day waiting period has been met or I
knowingly waive the 30 day waiting period.
Select one (1):
q I want the entire refund issued directly to me. I understand 20% of the taxable portion will be withheld for
federal income tax.
q I want my refund transferred directly to the retirement plan listed below. (Section 3 must be completed if you
select this option.)
q I want $_______________________ of the taxable portion of my refund transferred directly to the retirement
plan listed below and the remainder issued to me. (Section 3 must be completed if you select this option.)
SECTION 3. CERTIFICATION BY PLAN OR IRA ACCEPTING DIRECT TRANSFER (Must be
completed by plan which will receive direct transfer if you have requested that
all or part of your refund be transferred directly to another retirement plan.)
I agree to accept a direct transfer of the taxable portion of the refund due to the above named individual. I certify
that the plan named below is eligible for a transfer from the Tennessee Consolidated Retirement System, a
401(a) plan:
Name of Rollover Company
Type of Plan:
q Roth IRA q Traditional IRA Account Number
Mailing Address
City State Zip Code
Check Made Payable To
Contact Person Phone Number
Administrator’s Signature Date
TR-0026 (Rev. 6/2020) RDA-413
Page 3 of 3
SECTION 4. DIRECT DEPOSIT INFORMATION (Do not complete this section if you are
transferring or rolling over your account balance to another plan. Only complete
this section if you wish to have a cash distribution deposited into your bank
account.)
Type of Account: q Checking q Savings
Financial Institution
Routing Number Account Number
SECTION 5. CERTIFICATION BY EMPLOYER (To be completed by employer. Do not complete
if member has been out of work six months or more.)
q Political Subdivisions, Higher Education and State Departments Not Paid by Finance and Administration
Department Code ________-- _____
Eective Date of Termination (last paid day) ________________________________________________
This employee’s nal contribution will appear on the report for the month of ________________, 20_____.
(Allow for annual leave, if applicable.)
q Teachers
Department Code ________-- _____
Eective Date of Termination (last paid day) ________________________________________________
This employee’s nal contribution will appear on the report for the month of ________________, 20_____.
(Allow for annual leave, if applicable.)
q State Departments Paid by Finance and Administration
Department Code ________-- _____
Eective Date of Termination (last paid day) ________________________________________________
This employee’s nal contribution will appear on the report for the month of ________________, 20_____.
(Allow for annual leave, if applicable.)
Employer or Agent’s Signature Date
Employer or Agent’s Phone Number Employer Email
SECTION 6. TCRS REFUND TAX INFORMATION
The Special Tax Notice from the IRS can be found at https://treasury.tn.gov/Retirement/Information-and-
Resources/Forms-and-Guides. A paper copy of the Special Tax Notice can be obtained free of charge by calling
TCRS at (800) 922-7772.
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Application for Refund of Accumulated Contributions Tennessee Consolidated (State of Tennessee)

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Completed 27 January 2021

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