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: ,WPG
COMMONWEALTH OF MASSACHUSETTS | PUBLIC EMPLOYEE RETIREMENT ADMINISTRATION COMMISSION
WEB | WWW.MASS.GOV/PERAC
Application for Withdrawal of Accumulated Total Deductions
Form Last Revised: (GDTWCT[, 201
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
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
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
Application for Withdrawal of Accumulated Total Deductions 3
Member’s Last Name First M.I. Social Security #
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___________
Be aware that, if you take a refund of your retirement contributions, you will
terminate your membership and your rights in the retirement system. If you later
return to Massachusetts public service on or after April 2, 2012 after receiving a
refund, YOU WILL BE CONSIDERED A NEW EMPLOYEE and will be subject to
the pension reform changes included within Chapter 176 of the Acts of 2011.
These changes include, but are not limited to:
A new age factor table that will require you to work longer for the same or
a similar benefit that you would receive under today’s table.
An increase in the salary average period used in the retirement benefit
calculation formula from 3 years to 5 years.
An increase in the minimum retirement age from age 55 to 60.
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Important Notice
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 _________________________________________________
Application for Withdrawal of Accumulated Total Deductions
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).
Member’s Last Name First M.I. Social Security #
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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
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 $
*
Member’s Last Name First M.I. Social Security #
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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 
Member’s Last Name First M.I. Social Security #
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