Fillable DISTRIBUTION/DIRECT ROLLOVER/TRANSFER REQUEST (Government of the District of Columbia)

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DISTRIBUTION/DIRECT ROLLOVER/TRANSFER REQUEST (Government of the District of Columbia)

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FRM000-129-30516-201610-C2939 rev 10/2016
D.C. Department of Human Resources • 441 4th Street, NW, Suite 340N • Washington, DC 20001 • Toll Free 800-669-7400 • www.DCRetire.com • Fax 202-727-9070 1
DISTRIBUTION/DIRECT ROLLOVER/TRANSFER REQUEST
DISTRICT OF COLUMBIA 401(a) RETIREMENT PLAN
It is important to ensure you are using the most recent version of this form. Failure to do so will result in your
request not being processed. Visit www.DCRetire.com. This form can be found under the Forms tab.
If you are severing employment, you may leave your money in
the plan, begin taking distributions, or roll it over to another
eligible retirement plan that accepts such rollovers. If you are
70½ or older, you may be required to begin taking distributions
in accordance with the minimum distribution requirements.
You have a variety of distribution options available from which
to choose.
Only you can make this very personal decision after careful
consideration of several factors including your age, financial
needs, tax implications and other sources of income. You are
encouraged to consult with an accountant, financial planner
and/or tax advisor before making your final decision. While
our representatives are able to explain the options to you,
they cannot tell you which payment and tax-withholding
method is best for you. We cannot provide tax or legal advice.
Additionally, neither these instructions nor the Distribution
Form provides tax or legal advice relevant to your distribution.
ICMA-RC cannot release your funds until the District
of Columbia is able to confirm that you are entitled to
take a distribution or make a transfer from the Plan.
All completed forms must be returned to DCHR for
certification.
Incomplete or Inaccurate Information — In the event
any section of the Distribution Form is incomplete or inaccurate,
ICMA-RC may not be able to process the transaction requested
on the Distribution Form. You may be required to complete
a new form or provide additional information before the
transaction will be processed.
Changes to Your Request — If you make a change to the
Distribution Form as you are completing it, you must cross out
any previously elected choice(s) and initial all changes. If you
do not initial all changes, the Distribution Form will not be
processed and your form will be returned to you.
IN-SERVICE DISTRIBUTION
The following is a brief explanation of each of the withdrawal
options available if you are still employed with an employer
offering the plan.
70½ Withdrawal — You may take a distribution from your
plan at age 70½ even if you continue employment with the
employer that provides this plan. Complete the Installment
Payments section if you are electing installment payments as
an option.
DISTRIBUTION METHOD
All distributions will be distributed pro rata from your investment
funds unless you specify a fund specific request on a separate
piece of paper and return with this form.
Full Distribution — ICMA-RC will liquidate the funds from
all investment options in which you have a balance.
Partial Distribution — Indicate the amount of the partial
distribution you elect to receive. If your available balance is less
than the elected amount, the partial will be processed for the
amount of the remaining available balance.
Partial Distribution followed by installment payments
of an Amount Certain, or installment payments of a
Period Certain — For Phase 1 of your distribution, indicate
the gross amount of your initial partial distribution on the
line provided. For Phase 2 of your distribution, complete the
Installment Payment section.
Installment Payment — You must select a frequency, pay
date and either specific dollar amount or specific number of
years.
1. Payment of an Amount Certain — Indicate the gross
amount you wish to have distributed on a regular installment
basis (monthly, quarterly, semiannually or annually). Your
payments will continue until your account balance is
depleted. The number of payments you receive will vary
depending on the performance of your investments.
2. Payment of a Period Certain (Years) — You will receive
payments on a regular basis (monthly, quarterly, semi-annually
or annually). Payment amounts will depend on the length of
time in years during which you elect to receive payments,
the installment basis you choose, and the performance of
your investment options.
Your payment amount will be calculated by dividing your
current account balance by the number of remaining
payments. For example, if the payout is to be monthly for 4
years, the initial payout amount will be equal to 1/48 of the
account balance. The second payment will be 1/47 of your
balance, the third will be 1/46, and so on.
D.C. Department of Human Resources • 441 4th Street, NW, Suite 340N • Washington, DC 20001 • Toll Free 800-669-7400 • www.DCRetire.com • Fax 202-727-9070 2
FRM000-129-30516-201610-C2939 rev 10/2016
Your payment is recalculated each time a payment is
distributed; therefore, the amount of each payment will
never be the same. The payment amount will depend on
the account value, which may fluctuate depending upon
your chosen investments’ performance. Your balance will
be depleted by the end of the term you select.
Required Minimum Distribution (RMD) — What are the
Minimum Distribution Requirements? In general, the rules for
participants are as follows:
• You are required to begin taking minimum distributions
by April 1 of the calendar year following the later of the
calendar year you:
(1) reach age 70½, or
(2) retire from the employer sponsoring your Plan.
• Your RMD is calculated by dividing your prior year’s
December 31st account balance by the life expectancy
factor provided in the life expectancy tables contained in
the applicable Treasury regulations, using your age in the
current year.
• ICMA-RC will adjust your last payment of the year to ensure
your RMD amount is met.
• Any direct distribution you receive during the year counts
toward your RMD amount for that year.
• You may take your first minimum distribution during the year
you become 70½, or you may defer your first distribution no
later than April 1 of the following year.
• If you elect to defer your first distribution to April 1 of the
calendar year following the calendar year in which you turn
70½ or retire, you will be required to take two payments
that year: one by April 1 following the year in which you
turned 70½ or retired, and one by December 31 of that
same year. You must take a minimum distribution by
December 31 of every calendar year thereafter.
• If you are participating in more than one type of retirement
plan (i.e. 401(a), 403(b), IRA), your minimum distribution
must be calculated and taken separately from each plan.
• Your RMD amount must be paid directly to you. It cannot
be rolled over to another plan.
Direct Rollover to an Eligible Plan, IRA or Roth IRA
— You must determine whether your new employer’s plan or
IRA accepts eligible rollover distributions. If you do a rollover
to a governmental section 457(b) plan, please note that a later
distribution made before age 59½ will be subject to the 10%
additional income tax on early distributions (unless an exception
applies). The penalty tax characteristics are maintained since
you are transferring assets from a 401 plan.
Beginning in the later of the year you attain age 70½ or the
year during which you sever employment, you may not roll over
that portion of a distribution equal to your required minimum
distribution amount.
If you are requesting a direct rollover, an eligible rollover
distribution is paid from your Plan directly to an eligible
retirement plan or to a Traditional IRA.
Indicate the dollar amount you want to roll over (minimum
$200.00) and provide the company name, account number,
mailing address, city, state, zip code and a phone number
for your direct rollover. Once ICMA-RC has processed a direct
rollover, it cannot be returned.
If you choose this Distribution Method, a Form 1099-R will
be issued for reporting purposes; however, no federal income
tax will be automatically withheld from amounts directly
rolled over.
Direct Rollover to a Roth IRA — You are responsible for
determining if you are eligible to make a rollover to a Roth IRA.
If you roll your distribution directly into a Roth IRA, the entire
taxable portion of the rollover (amounts other than after-tax
contributions) will be taxable income to you in the year of the
rollover. Subsequent distributions from the Roth IRA may qualify
as tax-free distributions. You should consult with a tax advisor
to determine the tax consequences of future distributions from
the Roth IRA. No income tax withholding is required for any
taxable portion of your payment for which you choose a Direct
Rollover. However, you are responsible for paying the taxes due
for the year of distribution. You must have other money from
which you can pay the taxes. Generally, the 10% penalty tax
for distribution prior to age 59½ does not apply to the rollover.
However, it may later apply if you subsequently withdraw the
money from the Roth IRA under certain circumstances.
Once rolled to a Roth IRA, you cannot subsequently roll your
distribution to an employer plan, even if the Plan accepts
designated Roth contributions.
PAYMENT DELIVERY
The delivery of your distribution may depend on the Distribution
Method you elected on the Distribution form. Below is a
description of each delivery option.
Check — Checks are mailed to your address on record.
Automated Clearing House (ACH) — You may elect to
have your funds electronically deposited into your checking or
savings account. You must complete the Direct Deposit Form in
order to receive your funds via ACH.
D.C. Department of Human Resources • 441 4th Street, NW, Suite 340N • Washington, DC 20001 • Toll Free 800-669-7400 • www.DCRetire.com • Fax 202-727-9070 3
FRM000-129-30516-201610-C2939 rev 10/2016
FEDERAL AND STATE INCOME TAX
WITHHOLDING
Distribution withholding will vary depending on the type of
distribution you are requesting on the Distribution Form. You
have received and must read the attached Special Tax Notice,
which provides additional tax withholding information. You are
strongly urged to consult with your tax advisor to determine
your appropriate tax withholding.
Federal Income Tax Withholding
Full Distribution — 20% mandatory federal income tax
withholding will apply unless you elect a Direct Rollover of the
entire amount.
Partial Distribution — 20% mandatory federal income tax
withholding will apply unless you elect a Direct Rollover.
Installment Payment — 20% mandatory federal income tax
withholding will apply to all amount certain or period certain
installment payments scheduled to continue for less than 10
years. If your installment payments are scheduled to continue
for a period certain of more than 10 years, complete and attach
a Form W-4P to your Distribution Form. If a W-4P is not attached,
federal withholding will be made as though you are married with
three allowances.
Direct Rollover — Eligible rollover distributions that are
directly rolled over are not subject to federal tax withholding.
Mandatory District Tax Withholding
If the distribution from the plan is subject to mandatory
withholding of federal income tax, the District of Columbia (DC)
withholding tax formula is used to calculate withholding for all
nonqualified plan distributions. The withholding tax formula
is used to calculate withholding for periodic and withdrawal
distributions from qualified plans. Withholding for lump sum
distributions from qualified plan distributions is withheld at the
current rate set by the District of Columbia (DC). Participants
who live in other areas/states will experience withholding at
their state’s mandatory rate.
Early Withdrawal Penalty Tax
The 401(a) plan assets are subject to a 10% early distribution
penalty tax if withdrawn from your account prior to age 59½
unless an exception applies as follows:
1. Withdrawals on or after the day you turn 59½.
2. Withdrawals after your separation from service occurred in
the year you reached age 55 or older.
3. Withdrawals if you become disabled.
4. Withdrawals paid to your named beneficiary after death.
5. Withdrawals paid to an alternate payee under qualified
domestic relations orders (QDROs).
6. Funds rolled over into another Eligible Employer Plan or IRA
within 60 days of disbursement.
7. Withdrawals on a 72(t) “Qualified” payment schedule,
which is defined as:
a. Equal (or almost equal) payments at least annually over
your life expectancy, the life expectancy of you and your
beneficiary, or by using another IRS approved method
under IRC 72(t), and
b. Payments that must continue for the greater of 5 years
or until age 59½.
If your payments do not continue for 5 years or until 59½, all of
the money withdrawn will become subject to the 10% penalty.
Important Note
Please reference the Special Tax Notice Regarding Plan
Payments document for further details as they apply to
distributions from a retirement account.
Neither the District of Columbia, the plan sponsor, nor
ICMA-RC, the plan recordkeeper, gives legal or tax advice. You
may wish to consult with 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, 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.
FRM000-129-30516-201610-C2939 rev 10/2016
D.C. Department of Human Resources • 441 4th Street, NW, Suite 340N • Washington, DC 20001 • Toll Free 800-669-7400 • www.DCRetire.com • Fax 202-727-9070 4
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D.C. Department of Human Resources • 441 4th Street, NW, Suite 340N • Washington, DC 20001 • Toll Free 800-669-7400 • www.DCRetire.com • Fax 202-727-9070 5
FRM000-129-30516-201610-C2939 rev 10/2016
DISTRIBUTION/DIRECT ROLLOVER/TRANSFER REQUEST FORM
DISTRICT OF COLUMBIA 401(a) RETIREMENT PLAN | PAGE 1 OF 3
Please type or print with blue or black ink when completing the form. For additional instructions, please see page 1.
Employer Plan: 108208 — DC 401(a) Retirement Plan
1. PERSONAL INFORMATION 3. DISTRIBUTION METHOD
Full Distribution
Partial Distribution
Partial Amount $ or %
Partial Distribution followed by Installment Payments
(also complete Installment Payments below)
Partial Amount $ or %
Partial Distribution followed by Rollover (also complete
Direct Rollover/Transfer section on page 7)
Partial Amount $ or %
Installment Payments
New Installment
Change Installments
Stop Installments
If you selected Quarterly, Semi-Annually or Annually please
specify the month(s) that you want to receive your installments
here:
Monthly installments will begin as soon as administratively
possible and are processed on the closest business day to the
date you provide here:
/
/
1. Payments of an Amount Certain until the account is
exhausted:
Specified dollar amount: $
2. Payments of a Period Certain:
Specified time period of
years.
Required Minimum Distribution* Frequency:
Single Payment
Monthly
Quarterly
Semi-Annually
Annually
Monthly installments will begin as soon as administratively
possible and are processed on the closest business day to the
date you provide here:
/
/
Frequency:
Monthly
Quarterly
Semi-Annually
Annually
1. PERSONAL INFORMATION
Social Security Number:
–
–
(for tax-reporting purposes)
Date of Birth:
/
/
Date Employed:
/
/
Last Date of Employment:
/
/
Participant: Last name
first name/mi
Mailing Address/Street:
City:
State:
ZIP+4:
–
Daytime Phone Number: (
)
–
Evening Phone Number: (
)
–
Email Address:
Are You a U.S. Citizen? Yes No
2. IN-SERVICE DISTRIBUTION
Check only one box. A separate form is available at www.DCRetire.com.
Age 70½ Withdrawal
(complete Installment Payments section if setting up installments)
Amount $ or %
FRM000-129-30516-201610-C2939 rev 10/2016
D.C. Department of Human Resources • 441 4th Street, NW, Suite 340N • Washington, DC 20001 • Toll Free 800-669-7400 • www.DCRetire.com • Fax 202-727-9070 6
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D.C. Department of Human Resources • 441 4th Street, NW, Suite 340N • Washington, DC 20001 • Toll Free 800-669-7400 • www.DCRetire.com • Fax 202-727-9070 7
FRM000-129-30516-201610-C2939 rev 10/2016
If you selected Quarterly, Semi-Annually or Annually please
specify the month(s) that you want to receive your installments
here:
If you selected an annual payment and this is your first RMD,
please indicate if you want to be paid in the current year or paid
by April 1 of the next calendar year. Please select one:
First payment in current year
Defer to next calendar year (by April 1)
* Please note that if you elect an installment distribution of your
current tax year Required Minimum Distribution (RMD), the payment
amount will be calculated using your remaining RMD amount for
the current year and your payment may increase to ensure that you
meet the RMD each year. The RMD amount will be adjusted annually
based upon IRS life expectancy tables. Any remaining RMD amounts
not satisfied by the installment payment will be automatically made
payable to you in December of the applicable tax year. If this is your
first year for a RMD any additional amounts due and not satisfied by
the installment payment will be paid to you in April of the following
year in accordance with IRS regulations. Refer to page 2 for more
Required Minimum Distribution information.
Direct Rollover/Transfer
Provide company information below. Applies to full or partial
distribution options only. If a dollar amount or percentage to
roll over has not been provided, a full rollover will be processed.
Checks will be mailed to the receiving trustee’s address as
indicated below.
Amount of Rollover: $ or %
Rollover to an eligible plan
Rollover to an IRA (Traditional)
Rollover to a Roth IRA
Name of Receiving Trustee:
Address (Number and Street):
City:
State:
Zip Code + 4:
–
Account Number:
Name on Account:
SSN:
–
–
Name: Last, first, mi
DISTRIBUTION/DIRECT ROLLOVER/TRANSFER REQUEST FORM
DISTRICT OF COLUMBIA 401(a) RETIREMENT PLAN | PAGE 2 OF 3
4. PAYMENT DELIVERY METHOD
5. FEDERAL INCOME TAX WITHHOLDING
Check mailed to my address of record via U.S. Postal Service
ACH Direct Deposit — Payment deposited to my account at a
financial organization (Complete the attached direct deposit
form. Not available for rollovers/transfers.)
Federal taxes are mandatory and withheld at 20% for partial and
lump-sum payments, and for certain installment payments. Please see
instructions.
Additional Federal — We will withhold all required federal
tax withholding based on your distribution type. If you would
like additional federal tax withheld, indicate amount:
$ or %
Required Minimum Distribution — Select this option if
you are making a change to the RMD tax withholdings:
$ or %
Note: Federal income tax withholding applies to RMD payments at a
standard rate of 10%. You may elect not to withhold taxes or select a
different tax rate. If, while you are receiving installment payments, you
become RMD eligible, your installment payments will automatically be
converted to RMD payments until your annual minimum is met. The RMD
tax rate will be applied to any portion (up to 100%) of the installment
payments that apply to your RMD. The remaining portion of your
installment payment, once your RMD obligation has been satisfied, will
be taxed based on the rates that you have elected to withhold.
6. STATE INCOME TAX WITHHOLDING
Withholding for distributions from qualified plan distributions is withheld
at the current rate set by the District of Columbia (DC). Participants who
live in other areas/states will experience withholding at their state’s
mandatory rate.
Additional District — If you would like additional District
tax withheld, indicate amount:
$ or %
FRM000-129-30516-201610-C2939 rev 10/2016
D.C. Department of Human Resources • 441 4th Street, NW, Suite 340N • Washington, DC 20001 • Toll Free 800-669-7400 • www.DCRetire.com • Fax 202-727-9070 8
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D.C. Department of Human Resources • 441 4th Street, NW, Suite 340N • Washington, DC 20001 • Toll Free 800-669-7400 • www.DCRetire.com • Fax 202-727-9070 9
FRM000-129-30516-201610-C2939 rev 10/2016
SSN:
–
–
Name: Last, first, mi
DISTRIBUTION/DIRECT ROLLOVER/TRANSFER REQUEST FORM
DISTRICT OF COLUMBIA 401(a) RETIREMENT PLAN | PAGE 3 OF 3
The Internal Revenue Service requires a severance of employment
from employers providing the plan to qualify for a distribution.
I understand if I am convicted of a felony related to my covered
employment, my employer may direct any employer discretionary
contributions treated as non-elective employer contributions
be forfeited. Any person who knowingly presents a false or
fraudulent claim is subject to criminal and civil penalties.
My signature acknowledges that I have received, read, understand
and agree to all pages of the Distribution/Direct Rollover/
Transfer Request Form, the Participant Distribution Instructions,
and the Special Tax Notice, and affirm that all information that I
have provided is true and correct. I understand that it is entirely
my responsibility to ensure that this election conforms with all
applicable provisions of the Internal Revenue Code (the “Code”.)
I understand that I am liable for any income tax and/or penalties
assessed by the IRS for any election I have chosen. I understand
that I may not make changes to this request once a check has
been issued. If I have elected an installment payment, I may make
changes to future payments by completing a new distribution
form. In the event that any section of this form is incomplete or
inaccurate, DCHR may not approve the transaction requested on
this form and may require that I complete a new form or provide
additional or proper information before the transaction can be
processed.
I certify that this request is in compliance with applicable Plan
provisions and federal law and that the participant has received
any required notices. I acknowledge that I am currently not
working in any capacity for a public employer and it has been at
least one full calendar month since I last received compensation or
active employment benefits from an employer providing this plan.
Participant Signature
Date / /
It is important to ensure you are using the most recent version
of this form. Failure to do so will result in your request not
being processed. Visit www.DCRetire.com. This form can be
found under the Forms tab.
Please be sure to get your employer’s signature, your employer
will then forward to DCHR for approval. DCHR will submit your
completed form to ICMA-RC.
7. PARTICIPANT ACKNOWLEDGEMENT
FOR EMPLOYER USE ONLY. This section must be
completed and returned to ICMA-RC by DCHR. By signing,
the employer confirms the participant is eligible to receive
payments out of the retirement plan designated in section1.
This section does not need to be completed if the employer has
already notified ICMA-RC of the participant’s separation from
service. Your department head will forward the form to DCHR for
final signature.
Participant’s Last Day of Employment (mm/dd/yyyy):
/ /
Department Employer Signature
Date / /
Name (Please print)
Title
Vesting Status: %
DCHR Signature
Date / /
Name (Please print)
Title
8. EMPLOYER AUTHORIZATION
FRM000-129-30516-201610-C2939 rev 10/2016
D.C. Department of Human Resources • 441 4th Street, NW, Suite 340N • Washington, DC 20001 • Toll Free 800-669-7400 • www.DCRetire.com • Fax 202-727-9070 10
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D.C. Department of Human Resources • 441 4th Street, NW, Suite 340N • Washington, DC 20001 • Toll Free 800-669-7400 • www.DCRetire.com • Fax 202-727-9070 11
FRM000-129-30516-201610-C2939 rev 10/2016
Employer Plan: 108208 — DC 401(a) Retirement Plan
DIRECT DEPOSIT AUTHORIZATION FORM
Please type or print with blue or black ink when completing the form. For additional instructions, please see page 12.
PAYEE INFORMATION PARTICIPANT AUTHORIZATION
DIRECT DEPOSIT ACCOUNT INFORMATION
Social Security Number:
–
–
Daytime Phone Number: (
)
–
Participant: Last name
first name/mi
Please contact your bank for this information. Incorrect
information will delay electronic deposit processing. See back for
an example of a check and the information needed.
Type of Depositor Account: Checking Savings
Depositor Account Number:
Name on your bank account:
Name of Financial Institution:
Financial Institution’s Direct Deposit Routing Number:
Financial Institution’s Telephone Number:
(
)
–
I hereby authorize the VantageTrust Company (hereinafter
called the “Trust”) to credit the above referenced account. This
authorization agreement is to remain in full force and effect
until the Trust has received written notification from me of its
termination in such time and in such manner as to afford the
Trust and depository a reasonable opportunity to act on it. This
authorization agreement may also be terminated by the Trust.
In the event that the Trust notifies the bank that funds to which I
am not entitled have been deposited to my account inadvertently,
I hereby authorize and direct the bank to return said funds to the
Trust as soon as possible.
Participant Printed Name:
Participant Signature:
Date / /
PLEASE ATTACH A VOIDED CHECK HERE.
FRM000-129-30516-201610-C2939 rev 10/2016
D.C. Department of Human Resources • 441 4th Street, NW, Suite 340N • Washington, DC 20001 • Toll Free 800-669-7400 • www.DCRetire.com • Fax 202-727-9070 12
JOHN AND JANE DOE
1234 Main Street
Anytown, VA 11111
Pay to the
order of
Dollars
345
Memo
20
12-345/678
First National Bank
of Anytown, VA
Anytown, VA 11111
A. Be sure
current
address is
shown.
C. Your account number.B. Financial institution’s routing
number for direct deposit.
Please call your bank to
verify this number is correct
for direct deposit. If the
number is not correct, it will
result in delays.
DIRECT DEPOSIT AUTHORIZATION FORM INSTRUCTION
D.C. Department of Human Resources • 441 4th Street, NW, Suite 340N • Washington, DC 20001 • Toll Free 800-669-7400 • www.DCRetire.com • Fax 202-727-9070 13
FRM000-129-30516-201610-C2939 rev 10/2016
QUALIFIED JOINT AND SURVIVOR ANNUITY
(QJSA)
A QJSA pays benefits from the plan as a life annuity (a series
of payments, usually monthly, for life) to the participant and,
following the participant’s death, a survivor annuity is paid
over the life of the participant’s surviving spouse (or a former
spouse, child or dependent who must be treated as a surviving
spouse under a Qualified Domestic Relations Order). The
amount of the survivor annuity must be no less than 50% of
the amount of the life annuity paid to the participant.
WAIVING YOUR RIGHT TO A QJSA
A married participant must obtain written consent from his or
her spouse before payments from the account can begin, if the
participant requests any form of payment other than a QJSA.
For example, consent is required before a lump sum, direct
rollover or installment payment can be distributed. When you
waive your right to a QJSA, you consent to allow the participant
to withdraw money from the account as he or she chooses,
and the participant will be able to request future distributions
from the account without obtaining your consent. You have
the ability to revoke your consent at any time by contacting
ICMA-RC.
Please note that legal separation or divorce may end your right
to survivor benefits from the plan. If you are thinking about
separating or getting a divorce, you should seek legal advice
on your rights to benefits under the plan.
Waiving your right to a QJSA is a very important decision,
and you should make sure you understand the benefits you
would receive from a QJSA. Before signing the waiver, you may
contact ICMA-RC to obtain estimates of what your annuity
payments would be under the QJSA payment option.
SPOUSE SIGNATURE AND CONSENT
By signing Section 2, Spouse Signature and Consent, the
spouse of the participant, named in Section 1, understands and
acknowledges the following:
• I have the right to require the participant to have benefits paid
as a Qualified Joint and Survivor Annuity (QJSA).
• I consent to the participant receiving distributions from the
account by a method other than a QJSA, and I waive my right to
the benefits I would otherwise receive under a QJSA.
• By waiving my rights, the benefits I receive may be less than
what I would have received under a QJSA, and I may receive no
benefits at all after my spouse dies depending on the payment
option he or she chooses.
• The participant will be able to request future distributions from
the account without obtaining my consent.
• I have the ability to revoke my consent at any time by
contacting ICMA-RC at 800-669-7400.
• I am not required to sign this waiver form but I am doing so
voluntarily.
WAIVER OF QUALIFIED JOINT & SURVIVOR ANNUITY
(SPOUSAL CONSENT FORM)
DISTRICT OF COLUMBIA 401(a) RETIREMENT PLAN — 108208
FRM000-129-30516-201610-C2939 rev 10/2016
D.C. Department of Human Resources • 441 4th Street, NW, Suite 340N • Washington, DC 20001 • Toll Free 800-669-7400 • www.DCRetire.com • Fax 202-727-9070 14
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D.C. Department of Human Resources • 441 4th Street, NW, Suite 340N • Washington, DC 20001 • Toll Free 800-669-7400 • www.DCRetire.com • Fax 202-727-9070 15
FRM000-129-30516-201610-C2939 rev 10/2016
WAIVER OF QUALIFIED JOINT AND SURVIVOR ANNUITY
(SPOUSAL CONSENT FORM)
DISTRICT OF COLUMBIA 401(a) RETIREMENT PLAN | PAGE 1 OF 2
Both Married and Single Participants Must Complete
Employer Plan: 108208 — DC 401(a) Retirement Plan
1. PARTICIPANT INFORMATION
4. WITNESS — AUTHORIZED PLAN
REPRESENTATIVE OR NOTARY PUBLIC
2. SPOUSE SIGNATURE AND CONSENT
Social Security Number:
–
–
(for tax-reporting purposes)
Date of Birth:
/
/
Daytime Phone Number: (
)
–
Participant: Last name
first name/mi
Mailing Address/Street:
City:
State:
ZIP+4:
–
Email Address:
Signature of Participant’s Spouse:
Name (Please Print):
Date: / /
3. PARTICIPANT CERTIFICATION
To be completed by single participant.
I certify that I am single.
Signature of Participant
:
Name (Please Print):
Date: / /
The signature of the participant’s spouse must be witnessed by an
authorized representative of the employer-sponsored retirement
plan or a notary public.
Employer Plan Representative
Signature of Employer
:
Title:
Name (Please Print):
Date: / /
Subscribed and sworn to before me this day of
, 20 .
Notary Public:
My commission expires: / /
D.C. Department of Human Resources • 441 4th Street, NW, Suite 340N • Washington, DC 20001 • Toll Free 800-669-7400 • www.DCRetire.com • Fax 202-727-9070 16
FRM000-129-30516-201610-C2939 rev 10/2016
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FRM000-129-30516-201610-C2939 rev 10/2016
D.C. Department of Human Resources • 441 4th Street, NW, Suite 340N • Washington, DC 20001 • Toll Free 800-669-7400 • www.DCRetire.com • Fax 202-727-9070 17
Special Tax Notice Regarding Plan Payments
This notice applies to distributions from 401(a), 401(k), and 457(b) plans with ICMA-RC, including
distributions from Roth and non-Roth accounts in the plans (e.g., pre-tax, after-tax).
You are receiving this notice because all or a portion of a payment from your account is eligible to be rolled over to an IRA or an
employer plan. is notice is intended to help you decide whether to do such a rollover. Please review and consider the information in the
notice before you begin withdrawing funds from your account with ICMA-RC.
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.
ROLLOVER OPTIONS AVAILABLE
GENERAL INFORMATION ABOUT ROLLOVERS
What is a rollover?
A rollover is a payment from your employer sponsored retirement plan
that is transferred to another eligible employer plan (a tax-qualied plan,
section 403(b) plan, or governmental section 457(b) plan) or IRA (an
individual retirement account or individual retirement annuity). Assets
that are rolled over to another eligible plan or Traditional IRA are not
taxed until they are later withdrawn from the receiving plan.
How can a rollover affect my taxes?
Pre-Tax A ssets — 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).
Roth Assets — After-tax contributions included in a payment from a
designated Roth account are not taxed, but earnings might be taxed.
e tax treatment of earnings included in the payment depends on
whether the payment is a qualied 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 qualied 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 qualied distributions.
If the payment from the Plan is a qualied 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 qualied distribution.
A qualied 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 rst 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 employer plan, your participation will count from January1
of the year your rst 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?
Pre-Tax Assets — You may roll over the payment to either an IRA
(an individual retirement account or individual retirement annuity)
or an employer plan (a tax-qualied plan, section 403(b) plan, or
governmental section 457(b) plan) that will accept the rollover.
e 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 will become subject to the tax rules that apply to the IRA or
employer plan.
Roth Assets — 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 that will
accept the rollover (e.g., 457(b), 401(k), and 403(b) plans that allow
Roth contributions). e 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 rolled 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 dierences include:
• If you do a rollover to a Roth IRA, all of your Roth IRAs will be
considered for purposes of determining whether you have satised
the 5-year rule (counting from January 1 of the year for which your
rst 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 Roth IRAs (in order to determine your
taxable income for later Roth IRA payments that are not qualied
distributions).
• Eligible rollover distributions from a Roth IRA can only be rolled
over to another Roth IRA.
How do I do a rollover?
ere 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 or an employer plan. You should contact the IRA sponsor or
FRM000-129-30516-201610-C2939 rev 10/2016
D.C. Department of Human Resources • 441 4th Street, NW, Suite 340N • Washington, DC 20001 • Toll Free 800-669-7400 • www.DCRetire.com • Fax 202-727-9070 18
the administrator of the employer plan for information on how to do a
direct rollover.
If you do not do a direct rollover,
Pre-Tax A ssets — You may still do a rollover by making a deposit
into an IRA or eligible employer plan that will accept it. You will have
60 days after you receive the payment to make the deposit. 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 actually received). is 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).
Roth Assets — You may still do a rollover by making a deposit
within 60 days into a Roth IRA, whether the payment is a qualied
or nonqualied distribution. In addition, 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 nonqualied 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 qualied distribution. If you receive a distribution that is a
nonqualied 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 rst of earnings.
If you do not do a direct rollover and the payment is not a qualied
distribution, the Plan is required to withhold 20% of the earnings for
federal income taxes (up to the amount of cash and property actually
received). is 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 expectancy (or the lives or joint life expectancy of you and
your beneciary)
Required minimum distributions after age 70½ (or after death)
Hardship distributions
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 rst contribution
ICMA-RC 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, 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. is tax is in addition to
the regular income tax on the payment not rolled over.
e 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 in 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
beneciary)
Payments made due to disability
Payments after your death
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 qualied 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 (401(k) plans only)
Payments of certain automatic enrollment contributions requested to
be withdrawn within 90 days of the rst contribution.
If I do a rollover to an IRA (including a Roth 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 or the payment is a qualied
distribution of Roth assets. In general, the exceptions to the 10%
additional income tax for early distributions from an IRA are the same as
the exceptions listed above for early distributions from a plan. However,
there are a few dierences for payments from an IRA, including:
ere is no exception for payments after separation from service that
are made after age 55.
e exception for qualied domestic relations orders (QDROs) does
not apply (although a special rule applies 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).
e exception for payments made at least annually in equal or close
to equal amounts over a specied period applies without regard to
whether you have had a separation from service.
ere are additional exceptions for (1) payments for qualied higher
education expenses, (2) payments up to $10,000 used in a qualied
rst-time home purchase, and (3) payments for health insurance
premiums after you have received unemployment compensation
for 12 consecutive weeks (or would have been eligible to receive
unemployment compensation but for self-employed status).
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 dierence 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-qualied plan, a section 403(b) plan, or an IRA). However, if you
FRM000-129-30516-201610-C2939 rev 10/2016
D.C. Department of Human Resources • 441 4th Street, NW, Suite 340N • Washington, DC 20001 • Toll Free 800-669-7400 • www.DCRetire.com • Fax 202-727-9070 19
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 dierences are that you cannot do a rollover if
the payment is due to an “unforeseeable emergency” and the special rules
under “If you were born on or before January 1, 1936” do not apply.
Will I owe State income taxes?
is notice does not describe any State or local income tax rules
(including withholding rules).
SPECIAL RULES AND OPTIONS
If your payment includes non-Roth after-tax contributions
After-tax contributions included in a payment are not taxed. If a payment
is only part of your benet, 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 rst of the amount that
would be taxable if not rolled 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 which destination receives the after-tax
contributions.
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 le 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
Individual Retirement Arrangements (IRAs).
If you have an outstanding loan that is being offset
If you have an outstanding loan from the Plan, your Plan benet may be
oset by the amount of the loan, typically when your employment ends.
e loan oset amount is treated as a distribution to you at the time of
the oset 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 oset to an IRA or employer plan.
In the case of a nonqualied distribution of Roth assets, the preceding
sentence applies to the earnings.
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 you do not roll over, special rules for calculating the
amount of the tax on the payment (for Roth assets, on any earnings
taxed) might apply to you. For more information, see IRS Publication
575, Pension and Annuity Income.
If you are an eligible retired public safety ofcer and your payment is
used to pay for health coverage or qualied long-term care insurance
If the Plan is a governmental plan, you retired as a public safety ocer,
and your retirement was by reason of disability or was after normal
retirement age, you can exclude from your taxable income plan payments
paid directly as premiums to an accident or health plan (or a qualied
long-term care insurance contract) that your employer maintains for you,
your spouse, or your dependents, up to a maximum of $3,000 annually.
For this purpose, a public safety ocer is a law enforcement ocer,
reghter, chaplain, or member of a rescue squad or ambulance crew.
If you roll over your payment of non-Roth assets to a Roth IRA
If you roll over a 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 qualied distributions will not be taxed (including
earnings after the rollover). A qualied distribution from a Roth IRA is
a payment made after you are age 59½ (or after your death or disability,
or as a qualied rst-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
rst contribution was made to a Roth IRA. Payments from the Roth
IRA that are not qualied 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 you do a rollover from non-Roth assets to a designated Roth account
in the same Plan (in-plan Roth conversion)
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 designated Roth account within the 5-year period
that begins on January 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 qualied
distributions will not be taxed (including earnings after the rollover). A
qualied distribution from a designated Roth account is a payment made
FRM000-129-30516-201610-C2939 rev 10/2016
D.C. Department of Human Resources • 441 4th Street, NW, Suite 340N • Washington, DC 20001 • Toll Free 800-669-7400 • www.DCRetire.com • Fax 202-727-9070 20
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
rst contribution 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 rst 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 qualied 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).
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, the 10% additional income tax on early distributions and the
special rules for public safety ocers 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.
Pre-Tax Assets. 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 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.
Roth Assets. 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 nonqualied 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 distributions. 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 are a surviving beneciary other than a spouse. If you receive
a payment from the Plan because of the participant’s death and you
are a designated beneciary other than a surviving spouse, the only
rollover option you have is to do a direct rollover to an inherited IRA.
Payments from the inherited 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.
Payments under a qualied domestic relations order. If you are
the spouse or former spouse of the participant who receives a payment
from the Plan under a qualied 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 ling 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 dierent choice for later payments).
If your payments for the year (treating Roth and non-Roth assets
separately) are 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 can do a 60-day rollover.
Unless you elect otherwise, a mandatory cashout of more than $1,000 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 dierent choice for later payments).
If your payments for the year (treating Roth and non-Roth assets
separately) are 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 can do a 60-day rollover.
Unless you elect otherwise, a mandatory cashout of more than $1,000
(treating Roth and non-Roth assets separately) 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 benet does not exceed $5,000 (not including any amounts
held under the plan as a result of a prior rollover made 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.
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 nd 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). ese publications are
available from a local IRS oce, on the web at www.irs.gov, or by calling
1-800 -TA X-FOR M.
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DISTRIBUTIONDIRECT ROLLOVERTRANSFER REQUEST (Government of the District of Columbia)

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Completed 1 July 2021

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