Pension Protection Act Tax Exemption
Information Sheet
Under the guidelines of the federal Pension Protection Act (PPA) of 2006, eligible Public Safety Officers (PSO) may
annually exclude up to $3,000.00 of gross retirement income when it is distributed from a governmental defined
benefit plan and applied toward the payment of qualified insurance premiums. The West Virginia Legislature
extended this tax exclusion to West Virginia’s retired public safety officers during the 2007 Regular Legislative
Session. WV Code §5-10D-6a enables qualified PSO’s who are retired by any retirement plan administered by the
West Virginia Consolidated Public Retirement Board (CPRB) to elect to have a designated amount deducted from
their retirement benefits to pay for qualified insurance premiums.
This tax exclusion program is available to qualified public safety officers as defined by the federal Omnibus
Crime Control and Safe Streets Act of 1986 (42 U.S.C. 3796b(9)(A)):
Public Safety Officer means, individual serving a public agency in an official capacity, with or without
compensation, as a law enforcement officer, firefighter, chaplain for a police or fire department, or member of a
rescue squad or ambulance crew, corrections officer, probation officer, parole officer, judicial officer and any
other individuals involved in crime and juvenile delinquency control or reduction or enforcement of the laws.
Should you wish to participate in this tax exclusion program in 2021, please complete the enclosed 2021 PSOA
election form and return it along with your retirement packet. Please note that you are required to sign, date and
return both pages of the PSOA form to the CPRB.
The Pension Protection Act enables qualified public safety officers to exclude up to $3,000.00 of gross
retirement income each tax year.
This tax exclusion pertains to income distributed from a governmental defined benefit plan for payment of
qualified accident or health insurance premiums, including vision, dental and certain long-term care contracts.
To qualify for the tax exclusion, public safety officers must be separated from employment due to attainment of
normal retirement age or disability.
The amount of qualified insurance premiums excludable from gross income cannot exceed $3,000.00 per tax
year or the total amount of combined qualified insurance premiums paid in any taxable year.
The tax exclusion will become effective the first day of the month following CPRB’s receipt of completed
State of West Virginia
Consolidated Public Retirement Board
4101 MacCorkle Avenue SE, Charleston, West Virginia 25304-1636
Telephone: 304-558-3570 or 800-654-4406 Fax: 304-558-1394 or 304-558-5455
WVAF0008 Revised 11/30/2020
Instructions: The purpose of this form is to elect to have qualified health insurance premiums paid directly to an insurance provider and the cost
deducted from your monthly CPRB benefit. "Qualified health insurance premiums include certain accident or health insurance plans and certain long-
term care insurance contracts administered by an insurance company regulated by a State or an employer’s self-funded plan.” (PEIA is covered under
this definition.) Read “About PSOA -2021 Form” on page 2 before completing this form.
Retired Public Safety Officer
Authorization For Insurance
Premium Deduction
4101 MacCorkle Avenue, SE
Charleston, WV 25304
304-558-3570 or 800-654-4406
Consolidated Public Rerement Board
Section 1: Retiree Information
Employer at the Time of Retirement - Agency Name Job or Position Title at the Time of Retirement
Are you retired from more than one retirement system
administered by CPRB?
Yes No
Mailing Address City State
Zip Code
Retiree's Name
Last 4 Digits of SSN
Telephone Number
Section 2: Insurance Carrier Information
Change Previously Designated Payments
Stop Previously Designated Payments
Insurance Company Name Group/Policy Number
City State
Zip Code
Premium Payment Options (check one option only):
I hereby authorize CPRB to:
withhold entire monthly PEIA health insurance premium until $3,000 limit is met
withhold $_____________ monthly
CPRB may require proof of marriage and dependents
Coverage Type:
Daytime Telephone Number
Insurance Type:
Long-Term Care
Retiree Only Retiree and Spouse
Retiree, Spouse
and Dependents
withhold $_____________ as a one time payment
Section 3: Retiree Acknowledgement
I certify that I am eligible to have the designated insurance premiums excluded from taxable income, pursuant to Internal Revenue Code
Section 402(l) and WV Code § 5-10D-6a.
I authorize CPRB to pay the insurance premiums directly to the insurance carrier and deduct the cost from my monthly benefit. This will
result in a decrease in my monthly pension annuity.
I understand that the maximum amount of insurance premiums excludable from income from this retirement plan, as well as other
qualified government retirement plans, 403(b) plans and 457(b) plans, is $3,000 per year total.
I understand that it is my responsibility and obligation to inform CPRB of any change related to my qualified health insurance premium
deduction including, but not limited to, coverage, insurance company, or premium changes.
I understand that CPRB is performing an administrative function permitted by federal law in withholding insurance premiums from my
pension benefits.
I understand that any and all tax implications of my election are solely my responsibility, and I agree that I will make no claim against CPRB
for consequences of my election.
I understand that CPRB is not responsible for late fees, lapsed premiums or lapsed insurance policy coverage or any other coverage of
benefit issues that may arise between my insurance carrier and myself.
I understand this authorization is effective the first day of the month following CPRB’s receipt and expires December 31, 2021, providing
ICA is on file. A new authorization must be completed annually. Sign and date in BLUE INK.
NOTE: Once accepted by CPRB, this form supercedes all previously executed PSOA Forms under your retirement system.
Date Signed
Page 1 of 2
Is the Group Insurance Coverage/Policy Number or prepayment plan named above offered by your employer to Retirees?
Retiree Signature
The qualified health insurance premiums authorized to be paid will be deducted after all current deductions are withheld.
Check all that apply: New Designation
WVAF0008 - Jan 2016
WVAF0008 Revised 11/30/2020
1. Complete Sections 1 and 2 of the PSOA-2021 Form.
2. Attach a copy of the invoice for all qualifi ed health insurance payments, except PEIA.
3. Sign the form in blue ink and mail it to CPRB.
Note: Resubmit the PSOA-2021 Form if you have changes to a previously designated insurance provider or premium
amount or to stop insurance premium paymen ts.
About the PSOA-2021 Form
Page 2 of 2
Retiree Signature
Date Signed
By signing this form, I agree that I will not make any legal claim of any kind against CPRB, its staff and advisors should my participation
in this program result in unexpected tax liability to me, including interest and penalties. I understand that my ability to participate in
this program is a valuable benefit for which I am willing to agree to this waiver of all claims. I further release CPRB, its staff and advisors
from any liability arising from the administration of payments to any insurer.
This is a benefit enacted by congress and the IRS has not provided guidance to date on the application of this program. CPRB is
proceeding with implementation of the program based on its understanding of the information currently available, with the anticipation
that the program might require revisions and adjustments as the provisions of the Pension Protection Act of 2006 are interpreted and
clarified. By participating in the program, you acknowledge that changes may be required and that changes could affect your eligibility
or the eligibility of your insurance carrier or policy. It may also result in reversal of some transactions. You agree that any benefit or
privilege granted under this program is subject to change or revocation, that you will cooperate with any adjustments, and that CPRB is
not responsible for any consequence of any change to the program, including unexpected tax liability, interest and penalties.
Important Legal Notice
Waiver of Claims
Eligibility for Tax-Free Distributions for Health and Long-Term Care Insurance
Notes About Tax-Free Distributions For Insurance Premiums
Public Safety Officer means an individual serving a public agency in an official capacity, with or without compensation, as a law
enforcement officer, firefighter, chaplain for a police or fire department, or member of a rescue squad or ambulance crew,
correction officers, probation officers, parole officers, judicial officers, and any other individuals involved in crime and juvenile
delinquency control or reduction or enforcement of the laws.
Eligible Retired Public Safety Officer means an individual who, by reason of disability or attainment of normal retirement age, is
separated from service as a public safety officer with the employer who maintains the eligible retirement plan from which
distributions are made.
Upon the death of a Public Safety Officer, IRC 402(l) does not allow a surviving spouse or other beneficiaries to receive this tax-
free distribution.
Section 845 of the Pension Protection Act of 2006 allows public safety officers to elect to exclude up to $3,000 of distributions
from a governmental qualified retirement plan from taxable income as long as the payments are made directly to an insurer to
purchase health or long-term care insurance for the officer or the officer’s spouse and/or dependents.
Internal Revenue Code Section 402(l) and WV Code § 5-10D-6a authorize CPRB to offer this voluntary election, but only with
insurance carriers that have completed and filed the Retired Public Safety Officer Insurance Carrier Agreement (ICA) with the
CPRB. Requests from members for payment of premiums to insurance carriers who have not filed the ICA form will be referred
to the insurance carrier. CPRB may provide members a list of insurance carriers that have filed the ICA form upon request to
determine whether or not they will participate.
You must submit a separate copy of this form for each insurance policy you are designating for direct payment by CPRB.
The insurance premiums you designate on this form will be paid directly to the named insurance company by CPRB and the cost
will be deducted from your monthly benefit.
The cost of insurance premiums, up to $3,000, is excluded from your taxable income for federal withholding purposes.
You can use income from more than one retirement plan to pay insurance premiums, but the maximum income exclusion the
I.R.S. allows for all plans combined is $3,000 per year. You are responsible for complying with this federal limit and for
consequences if your designated insurance premiums exceed the limit.
Premium payments will begin upon the CPRB’s approval of your insurance carrier and after CPRB receives a completed and
signed PSOA-2021 Form. Incomplete and unsigned forms will not be processed and you will be notified that you must resubmit
the form.
You are responsible for contacting your insurance carrier should an over/underpayment of premiums occur due to CPRB not
being notified of premium changes or policy cancellations.
The form must be signed and dated to be valid.
I have read and I understand the information in “About the 2021 PSOA Form” and agree to all of the conditions for this election including the Waiver of Claims.
Normal retrirement age for determination of eligibility means a member who has retired with an unreduced benefit.
Insurance Carrier Participation
WVAF0008 - Jan 2016
WVAF0008 Revised 11/30/2020