APPLICATION FOR REFUND OF CONTRIBUTIONS - GDCP
1. Please print or type clearly.
2. Send this form to your Payroll Department.
Do not send to Georgia Defi ned Contribution Plan (GDCP).
3. If the taxable portion (interest earned) of your refund is
than $200.00, GDCP will withhold federal income tax. Typically the rate is
less than $200.00, GDCP will withhold federal income tax. Typically the rate isless
30%, or if you are over 59 1/2 , the withholding rate is 20%.
4. If the taxable portion (interest earned) of your refund is
than $200.00, GDCP is required to withhold federal income tax unless
you directly roll over the taxable portion to another eligible retirement plan. You will be notifi ed by GDCP if this applies to you.
Refunds include accumulated employee contributions and credited interest earnings (if any).
Upon receipt of refund application in this offi ce, please allow 8 weeks for processing.
SECTION 1 - MEMBER INFORMATION
Two Northside 75 Suite 300 • Atlanta, GA 30318
PHONE (404) 350-6300 (800) 805-4609
I understand that by receiving this refund I waive all rights to benefi ts accrued from this system.
Member Signature: ____________________________________________ Date:__________________________
Please provide the following dates for the above mentioned employee (if applicable).
______/_____/_______ Last Payroll Deduction: ______/_____/_______
Salary: $______________________
ns: $______________ for ______/_______ns: $______________
__________________________________________________
___________________________________________________ __________________________________________________
(Last) (First) (MI) (Maiden)
Mailing Address: _____________________________________________________________________________________________
(Street) (City) (State) (Zip Code)
E-mail : ___________________________
____/____/____ E-mail : ___________________________ ____/____/____
Daytime Phone No: (_______) __________________
State Agency/Department/School System/Unit of the Board of Regents in which you were employed: __________________________
___________________________________________________________________________________________________________
I certify that this employee has terminated employment, and that the total salary and contributions listed above are for the
Payroll Offi cer Signature: _________________________________________________ Date:
Agency #: ______________________________________
Telephone #: (________) - __________________________ Email Address: _____________________________________
