Instruction for form #459-401 SL3 (10/1/2018)
Member Account Withdrawal Application Packet
Important Information
There are several important factors to consider when deciding whether to withdraw your member account(s):
Your Tier One, Tier Two, and/or IAP disbursement is based on the account balance at the time PERS processes the
payment, not the date you select to withdraw.
Tier Two and IAP accounts are credited with investment earnings and losses annually and are subject to loss exposure
until your account(s) is distributed.
Tier Two and IAP accounts have no guaranteed rate of return.
Withdrawal eligibility
You must be separated from all PERS employers, including substitute, temporary, and on-call positions, to apply for a
withdrawal of your account. You must remain separated from all PERS employers for the full calendar month following the
month you terminated employment with your last PERS employer. The calendar month must run from the first day of the
month through the last day (example: If you terminate any day in February, you cannot return to work until April 1). PERS
will not issue a withdrawal check until this separation period has elapsed. If PERS issues a withdrawal and later discovers the
above criteria were not met, you must return the withdrawn amount(s) for redeposit into your Tier One/Tier Two and/or IAP account(s).
Please ensure that you have terminated employment with all PERS employers. If you are unsure of which employers you
have worked for, please contact PERS Member Services toll free at 888-320-7377.
You can withdraw your account balance if you are not yet eligible for a service retirement.
Separate withdrawal eligibility rules and withdrawal applications apply to judge members and alternate payees (APs) with
separate accounts (see the PERS website for the Judge Members Handbook and AP eligibility information). Contact
Member Services toll free at 888-320-7377 for the AP withdrawal application.
This packet contains:
Instructions for Member Account Withdrawal Application Packet
Instructions for Member Account Withdrawal Application form
Member Account Withdrawal Application form
Instructions for Withdrawal Direct Transfer Rollover Acceptance form
Withdrawal Direct Transfer Rollover Acceptance form
Verification of Age
Federal Tax Information Disclosure
W-9: IRS Request for Taxpayer Identification Number and Certification
If you want to withdraw your account(s), complete the following forms:
Member Account Withdrawal Application form
Withdrawal Direct Transfer Rollover Acceptance form (if applicable)
W-9: IRS Request for Taxpayer Identification Number and Certification
Return the forms to:
PERS
PO Box 23700
Tigard, OR 97281-3700
Fax: 503-598-0561
How to avoid common errors
1. Sign and date forms.
2. If your name has changed from the name PERS has on record, you must submit a copy of the legal document authorizing
your name change (e.g., divorce decree, marriage license, etc.) and an Information Change Request. This form is
available on the PERS website. Write “Withdrawal pending” on the form, and submit it with your withdrawal application.
Complete the application and all other forms using your new name as shown on your legal documentation.
11410 SW 68th Parkway, Tigard OR 97223
Mailing Address – PO Box 23700, Tigard OR 97281-3700
Toll free – 888-320-7377 Fax – 503-598-0561
Website – https://oregon.gov/pers
Instruction for form #459-401 SL3 (10/1/2018)
Member Account Withdrawal Application Packet
Important: Read instructions before you complete and submit forms.
Things to consider
Most applications will be processed within 120 days from your effective withdrawal date, which is the first of the month
following the receipt of your withdrawal application.
Information for Tier One/Tier Two members
By withdrawing your Tier One/Tier Two member account, you forfeit all membership rights in the Tier One/Tier Two
program. Withdrawals do not include an employer match of dollars. You may restore membership rights if:
• you are reemployed in a PERS-qualifying position within five years from the date you separated from all PERS-
covered employers, and
• you redeposit your withdrawal amount, plus interest, within one year of reemployment.
This will be your only opportunity to restore your Tier One or Tier Two membership rights.
Information for OPSRP Pension Program members
You must enter your date of birth in the area provided in Section A. You must also present documents to verify your age.
You will find a list of acceptable verification of age documents after the application instructions.
You cannot withdraw from the OPSRP Pension Program unless you are vested in that program and the present value
of your accrued benefit is $5,000 or less. You become vested in the OPSRP Pension Program when you have made
qualifying contributions in each of five calendar years or when you reach normal retirement age.
By withdrawing from the OPSRP Pension Program you forfeit all rights in that program. You cannot restore those rights.
Information for Individual Account Program (IAP) members
By withdrawing from the IAP you forfeit all rights in that program. You cannot restore those rights.
Page 1
Which forms do I need?
You must complete and submit the Member Account Withdrawal Application.
If you are rolling over any portion of your withdrawal, you must also submit the Withdrawal Direct Transfer
Rollover Acceptance form.
Complete and submit an Internal Revenue Service (IRS) Form W-9: Request for Taxpayer Identification Number and Certification.
General instructions
Type or print clearly in dark ink. Illegible forms may be returned, which could delay your request.
• Do not cross out, modify, or alter the application in any way—this could void your application
Deliver, fax (503-598-0561), or mail the Member Account Withdrawal Application and IRS Form W-9 to PERS.
Include the Withdrawal Direct Transfer Rollover Acceptance form, if applicable.
PERS cannot process the Withdrawal Direct Transfer Rollover Acceptance form until we receive the Member Account
Withdrawal Application. We recommend submitting both documents together.
If we do not receive complete and accurate forms within 180 days from the date we receive your application, we may
cancel your application.
Note: Please notify PERS if your address changes after receiving your distribution. We will mail your IRS Form 1099-R
(tax form) by January 31 to the address you indicate in Section A on the application (unless you change your address with
the Information Change Request form).
11410 SW 68th Parkway, Tigard OR 97223
Mailing Address – PO Box 23700, Tigard OR 97281-3700
Toll free – 888-320-7377 Fax – 503-598-0561
Website – https://oregon.gov/pers
Instruction for form #459-401 SL3 (10/1/2018)
Fill in the personal information block completely. If you do not know your PERS ID, leave it blank.
Providing your Social Security number (SSN) is mandatory, and PERS is authorized to request it under
provisions of the Internal Revenue Code. It will be used primarily to comply with mandatory IRS reporting. It may also
be used for confirmation purposes or recovery of overpaid funds.
You must enter your Social Security number (SSN) or Individual Tax Payer Identification Number (ITIN) even if you are
a nonresident alien (see tax and residency explanation in Section E on page 3 of these instructions).
Page 2
Section A: Member information
Check All of my eligible PERS accounts to apply for a withdrawal of all of your PERS member accounts. If you check
this box, you will receive a withdrawal of all applicable accounts [this includes Tier One, Tier Two, IAP, OPSRP Pension
Program, police and firefighter (P&F) unit account, and Loss of Membership (LOM) account].
Check My P&F unit account to withdraw only your P&F unit account. This withdrawal cancels your P&F unit account
and prevents you from contributing to or participating in the P&F unit account in the future, even when employed in
another P&F position.
Check My Loss of Membership (LOM) account to withdraw only your LOM account.
Note: To apply for a withdrawal of your alternate payee (AP) account, you will need to complete an Alternate Payee Account
Withdrawal Application. Contact PERS Member Services toll free at 888-320-7377 for the AP Withdrawal Application.
Section B: Account withdrawal selection
Section C: Withdrawal payment options
The withdrawal payment option you choose will apply to all accounts you withdraw.
Check Cash Option if you want PERS to pay you directly.
Check Direct Transfer Rollover if you want PERS to roll over all or any portion of your withdrawal amount.
• The rollover amount from all accounts must total at least $200.
• If you checked this box, you must fill out the Withdrawal Direct Transfer Rollover Acceptance form.
If you are splitting the withdrawal amount between the cash option and the direct transfer rollover:
Clearly indicate the percentage or dollar amount you want to roll over. We will mail the remaining balance to you after
withholding 20 percent federal tax and, if appropriate, Oregon state tax from the taxable portion of your withdrawal.
If you do not specify a percentage or dollar amount to be rolled over, PERS will roll over 100 percent of your withdrawal.
Instructions for Member Account Withdrawal Application
Please read the Federal Tax Information Disclosure included in this package.
Check Do not withhold 8 percent Oregon state tax if you do not want PERS to withhold 8 percent Oregon state tax. The 8
percent will be withheld unless you check this box.
If you want additional Oregon state tax withheld, enter the total additional dollar amount you want withheld in the space provided.
PERS is required by federal law to withhold 20 percent for federal tax from the taxable amount which is sent directly to the
IRS.
If you want more than the 20 percent federal tax withheld, enter the total additional dollar amount you want withheld in
the space provided. If you are withdrawing multiple accounts and direct PERS to withhold an additional amount, that amount
will be withheld from a single account.
Check I am a U.S. citizen or resident alien if you are a U.S. citizen or a resident alien and complete the enclosed IRS form
W-9: Request for Taxpayer Identification Number and Certification.
Check I am a non-resident alien if
you are a non-resident alien
and complete IRS Form
W-8BEN: Certificate of Foreign Status of
Beneficial Owner for United States Tax Withholding.
This form is available in the Forms section of the PERS website.
Section D: Tax and residency
(PERS must withhold 20 percent federal income tax from any taxable amount paid directly to you)
11410 SW 68th Parkway, Tigard OR 97223
Mailing Address – PO Box 23700, Tigard OR 97281-3700
Toll free – 888-320-7377 Fax – 503-598-0561
Website – https://oregon.gov/pers
Instruction for form #459-401 SL3 (10/1/2018) Page 3
The IRS requires PERS to notify you of the tax consequences of taking a withdrawal by providing the Federal
Tax Information Disclosure.
You have 30 days to review your withdrawal options and the associated tax consequences. PERS will not process
your withdrawal payment until the 30-day period has passed unless you check the box to waive your right to this
30-day period. If you check the waiver box, PERS will process your withdrawal as soon as possible.
You must sign and date the application. Deliver, fax, or mail the application to PERS. Keep a copy for your records.
If PERS is unable to process your withdrawal within 180 days from the date we receive your application, the
IRS requires us to provide the Federal Tax Information Disclosure again, and you will need to complete a new
Acknowledgement of Receipt of Federal Tax Information Disclosure form. We will contact you if this happens.
Section F: Member signature and federal tax 30-day waiver: Required
Section E: Residency certication (required)
If you are a Tier One member (hired into a PERS-covered position before January 1, 1996), by law you must declare if
your benet payment(s) will be subject to Oregon state income tax based on your residency.
You must check one of the statements in Section E.
You must sign the form to declare your residency. If you fail to provide a signature in this section, this form will
be returned for signature, which may cause a delay processing your benefits.
Member signature (do not print) Date
Section F: Member signature and federal tax 30-day waiver: Required
By signing below, I acknowledge the following: The information I have provided above is correct, and I have received and
read the Federal Tax Information Disclosure.
I have terminated my employment with all PERS employers as of the date of
this application. I understand I cannot return to work for a PERS-covered employer for the full calendar month following
the month in which I left employment. The calendar month must run from the first day of the month through the last day
(example: If I terminate any day in February, I cannot return to work until April 1). PERS will not issue my withdrawal
check until I meet these criteria.
q I waive my right to the 30-day period for reviewing the Federal Tax Information Disclosure.
Which accounts do you want to withdraw?
q All of my eligible PERS accounts. q Only my P&F unit account. q Only my Loss of Membership (LOM) account.
Section C: Withdrawal payment options (the option you choose will apply to all accounts you withdraw)
q Cash Option Please issue my withdrawal payment(s) directly to me.
q Direct Transfer Rollover** Rollover 100 percent or _________ percent or $____________ of my rollover-eligible
withdrawal amount to my IRA or eligible employer plan.
**
If you select this option, you must also fill out and submit the Withdrawal Direct Transfer Rollover Acceptance form.
Member Account Withdrawal Application
Section B: Account withdrawal selection
Section A: Member information
(Type or print clearly in dark ink. Illegible forms may be returned to you. This could delay your request.)
*Providing your Social Security number (SSN) is mandatory, and PERS is authorized to request it under provisions of the Internal Revenue Code. It will primarily be used to comply with mandatory IRS reporting.
It may also be used for conrmation purposes or recovery of overpaid funds.
q Do not withhold 8 percent Oregon state income tax (8 percent will be withheld if you do not check this box).
Do you want additional tax withheld?
Yes, withhold $_____________ more than the 8 percent for Oregon state income tax.
Yes, withhold $_____________ more than the mandatory 20 percent federal tax.
q I am a U.S. citizen or resident alien, and I have completed and included my IRS Form W-9.
q I am a non-resident alien, and I have completed and included my IRS Form W-8BEN.
Section D: Tax and residency (PERS must withhold 20 percent federal income tax from any taxable amount paid directly to you)
First name MI Last name Social Security number*
Mailing address (street or PO box) PERS ID (optional)
City State Zip Country Date of birth (mm-dd-yyyy)
Day phone number Evening phone number Email (optional)
In compliance with the Americans with Disabilities Act, PERS will provide help filling out this form upon request. You may request help by calling toll free 888-320-7377,or TTY 503-603-7766.
If you are a Tier One member (hired into a PERS-covered position before January 1, 1996), you must check one of the boxes below.
q I am a resident of the state of Oregon; therefore, payments made to me as a result of this application will not be
exempt from Oregon personal income tax by reason of non-residency.
q I am not a resident of the state of Oregon; therefore, payments made to me as a result of this application will not be
subject to Oregon personal income tax.
I hereby declare that the above statement is true to the best of my knowledge and belief, and I understand it is subject to
penalty for perjury.
Section E: Residency certication (required)
Member signature (do not print) Date
11410 SW 68th Parkway, Tigard OR 97223
Mailing Address – PO Box 23700, Tigard OR 97281-3700
Toll free – 888-320-7377 Fax – 503-598-0561
Website – https://oregon.gov/pers
Form #459-401 (10/1/2018) SL3 IIM Code: 2303
Instruction for form #459-401 SL3 (10/1/2018) Page 4
Fill in the personal information block completely. If you do not know your PERS ID, leave it blank.
Providing your Social Security number (SSN) is mandatory, and PERS is authorized to request it under provisions
of the Internal Revenue Code. It will be used primarily to comply with mandatory IRS reporting. It may also be
used for confirmation purposes or recovery of overpaid funds.
COMPLETE SECTION B OR C, BUT NOT BOTH
Section A: Member information
Use this form only if you select the Direct Transfer Rollover option in Section D on the Member Account
Withdrawal Application.
PERS cannot process the Withdrawal Direct Transfer Rollover Acceptance form until we receive your Member
Account Withdrawal Application.
Section B: IRA information
Consult your nancial institution if you need help completing this section.
Provide the IRA account number if available. This is not your Social Security number. Your nancial institution
can provide this information.
Indicate whether the IRA is a traditional IRA or a Roth IRA by checking the appropriate box.
The nancial institution name you enter will be the payee on the rollover check.
Provide the complete mailing address for the nancial institution.
Provide the nancial institution’s phone number.
Tier One/Tier Two and OPSRP Pension Program rollover checks will be sent to your nancial institution.
IAP account rollover checks will be sent to you directly for you to forward to your nancial institution.
Section C: Eligible employer plan information
(includes 457 deferred compensation plans)
Make sure your plan administrator or nancial institution completes and signs this section.
As the plan administrator or nancial institution, you will need to:
Check the box acknowledging whether the plan will or will not accept and separately account for after-tax
contributions.
Sign and date as the authorized plan representative. We cannot process the rollover without a signature.
Print your name and title.
On the lines provided, tell us to whom the check should be made payable, the mailing address, and the phone
number of the financial institution where the check should be mailed.
Section D: Authorization and signature
If you wish PERS to release information to your authorized representative, check the box and write in the
authorized representative’s name. Sign and date the form.
Instructions for Withdrawal Direct Transfer Rollover Acceptance
11410 SW 68th Parkway, Tigard OR 97223
Mailing Address – PO Box 23700, Tigard OR 97281-3700
Toll free – 888-320-7377 Fax – 503-598-0561
Website – https://oregon.gov/pers
Form #459-401 (10/1/2018) SL3 IIM Code: 2157C
Withdrawal Direct Transfer Rollover Acceptance
Section B: IRA Information
As an authorized representative, agent, custodian, trustee, or plan administrator of an eligible employer plan, I hereby
accept the direct transfer rollover from the Oregon Public Employees Retirement Systems plan, an eligible employer
retirement plan under Internal Revenue Code 401(a), as specified below.
Choose one: The plan q will q will not accept and separately account for after tax dollars.
Section C: Eligible employer plan information
Section D: Authorization and signature
In compliance with the Americans with Disabilities Act, PERS will provide help filling out this form upon request. You may request help by calling toll free 888-320-7377 or TTY 503-603-7766.
Section A: Member information
(Type or print clearly in dark ink. Illegible forms may be returned to you. This could delay your request.)
Complete either Section B or Section C, not both
q Traditional IRA q Roth IRA Account number (if available) ______________________________
Payable to (name of nancial institution)
________________________________________________________
Financial institution mailing address (street or PO box)
_____________________________________________
City __________________________ State _____ Zip
________________
Phone number
_________________
Authorized representative signature
_______________________________
_
______
Date
___
__
___________
Print name and title
______________________________
______________________________________
____
Make rollover payable to _____________________
__________________________
_____________________
Client’s account number (if available) _
___________________________________________
______________
Financial institution mailing address (street or PO box)
_____________________________________________
City __________________________ State _____ Zip
_
_______
________
Phone number
________________
PERS cannot process the Withdrawal Direct Transfer Rollover Acceptance form until we receive your
Member Account Withdrawal Application.
q I authorize PERS to release account information to ____________________
__
_______________________.
(authorized representative’s name)
First name MI Last name Social Security number*
Mailing address (street or PO box) PERS ID (optional)
City State Zip Country Date of birth (mm-dd-yyyy)
Day phone number Evening phone number Email (optional)
*
Providing your Social Security number (SSN) is mandatory, and PERS is authorized to request it under provisions of the Internal Revenue Code. It will primarily be used to comply
with mandatory IRS reporting. It may also be used for conrmation purposes or recovery of overpaid funds.
Member signature (do not print)
Date
By signing below, I acknowledge the above information is correct.
11410 SW 68th Parkway, Tigard OR 97223
Mailing Address – PO Box 23700, Tigard OR 97281-3700
Toll free – 888-320-7377 Fax – 503-598-0561
Website – https://oregon.gov/pers
Verification of Age
Photocopies of birth-date documents and, if applicable, beneficiary birth-date documents are required before
benefits are paid. We will not accept documents that are incomplete, appear to be altered, or are difficult to
read. If your documents are not accepted, you will need to submit new photocopies. Please include your
PERS ID or Social Security number* on all documents submitted, including beneficiary forms.
If it is impossible for you to furnish the proof required in Group 1 or 2, write to PERS with a full explanation.
Since the documents submitted cannot be returned, we suggest using photocopies. If it is illegal to copy a
document, bring it in, and PERS will verify the birth information.
Be sure to put the PERS members Social Security number on all documents so they are properly recorded.
Copy of Oregon drivers license or ID card if issued
on or after February 4, 2008
Birth verification issued by state, county, or coun-
try (Documents issued by foreign governments
in a language other than English need to include a
translation into English certified by a notary public,
public agency, or other public official.)
American Indian Reservation Age Verification
Infant baptism certificate
Hospital birth certificate (if signed by attending
physician or issued by state)
Passport (current or expired)
School-age record
Naturalization or citizenship papers
Family Bible record (If this record is furnished,
include the following information certified by a
notary public or other public official: copy of all
family record entries in the Bible referring to appli-
cant and parents, brothers, and sisters; Bible pub-
lication date or apparent age of Bible; when birth
date was entered and by whom.)
Group 1
If one item in this group is furnished showing birth
dates, no further evidence of age is needed.
Any ONE of these:
Group 2
Two items in this group from different sources are sufficient
if age or birth date is shown.
Any TWO of these:
Example: One child’s birth certificate and one drivers license.
Reference: OAR 459-013-0040 FS 459-029 (2/14/2018)
A notarized affidavit by an older, immediate family
member in a position to know the birth date (e.g.,
father, mother, etc.)
Certificate of military record
Marriage record (Record must show your age or
date of birth at time of marriage.)
Copy of Oregon driver’s license or ID card if issued
before February 4, 2008, or any other state’s
license or ID card issued at any time
County voter registration (Must show your age or
date of birth; do not send in your precinct card.)
Copy of child’s birth certificate if it shows age of
parents
Social Security record (Record must be displayed
on an estimate of benefits or screen print from the
Social Security office. Document must be dated
within last 12 months.)
Military ID (military record DD214)
Concealed weapons permit
11410 SW 68th Parkway, Tigard OR 97223
Mailing Address – PO Box 23700, Tigard OR 97281-3700
Toll free – 888-320-7377 Fax – 503-598-0561
Website – https://oregon.gov/pers
FS 459-042 (6/1/2020)
Page 1 of 5
11410 SW 68th Parkway, Tigard OR 97223
Mailing Address – PO Box 23700, Tigard OR 97281-3700
Toll free – 888-320-7377 Fax – 503-598-0561
Website – https://oregon.gov/pers
You are receiving this notice because all or a portion of a distribution you are receiving from your PERS
Chapter 238 Program (Tier One/Tier Two) or Oregon Public Service Retirement Plan (OPSRP) Pension
Program or Individual Account Program benet is eligible to be rolled over to an IRA or an employer plan. This
notice is intended to help you decide whether to do such a rollover.
Rules that apply to most distributions from PERS 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.
General information about rollovers
Federal Tax Information Disclosure
How can a rollover affect my taxes?
You will be taxed on your distribution from PERS 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 percent 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 distributions
later and the 10 percent additional income tax will not apply if those distributions are made after you are age
59½ (or if an exception applies).
Where may I roll over the distribution?
You may roll over the distribution 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. The rules of the IRA or employer plan that holds the rollover will determine your
investment options, fees, and rights to distribution 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.
How do I do a rollover?
There 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, PERS will make the distribution directly to your IRA or an employer plan. You
should contact the IRA sponsor or the administrator of the employer plan for information on how to do a direct
rollover.
If you do not do a direct rollover, 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 distribution to make the deposit.
If you do not do a direct rollover, PERS is required to withhold 20 percent of the distribution for federal income
taxes. This means that, in order to roll over the entire distribution in a 60-day rollover, you must use other funds
to make up for the 20 percent withheld. If you do not roll over the entire amount of the distribution, the portion
not rolled over will be taxed and will be subject to the 10 percent additional income tax on early distributions if
you are under age 59½ (unless an exception applies).
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 distribution
from PERS is eligible for rollover, except:
• Certain distributions 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 70 ½ (if born before July 1, 1949), age 72 (if born after June 30,
1949), or after death.
• Hardship distributions
FS 459-042 (6/1/2020)
Page 2 of 5
• Corrective distributions of contributions that exceed tax law limitations
• Cost of life insurance paid by PERS
• Contributions made under special automatic enrollment rules that are withdrawn pursuant to your request
within 90 days of enrollment
The PERS administrator or the payer can tell you what portion of a distribution is eligible for rollover.
If I don’t do a rollover, will I have to pay the 10 percent additional income tax on early distributions?
If you are under age 59½, you will have to pay the 10 percent additional income tax on early distributions for
any distribution from PERS (including amounts withheld for income tax) that you do not roll over, unless one
of the exceptions listed below applies. This tax is in addition to the regular income tax on the distribution not
rolled over.
The 10 percent additional income tax does not apply to the following distributions from PERS:
• Distributions made after you separate from service if you will be at least age 55 in the year of the separation
• Distributions 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)
• Distributions from a governmental dened benet pension plan made after you separate from service if you
are a public safety employee and you are at least age 50 in the year of the separation
• Distributions made due to disability
• Distributions after your death
• Corrective distributions of contributions that exceed tax law limitations
• Cost of life insurance paid by PERS
• Contributions made under special automatic enrollment rules that are withdrawn pursuant to your request
within 90 days of enrollment
• Distributions made directly to the government to satisfy a federal tax levy
• Distributions made under a qualied domestic relations order (QDRO)
• Distributions up to the amount of your deductible medical expenses
• Certain distributions 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
• Distributions of certain automatic enrollment contributions requested to be withdrawn within 90 days of the
rst contribution
If I do a rollover to an IRA, will the 10 percent additional income tax apply to early distributions from the IRA?
If you receive a distribution from an IRA when you are under age 59½, you will have to pay the 10 percent
additional income tax on early distributions from the IRA, unless an exception applies. In general, the
exceptions to the 10 percent 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 differences for distributions
from an IRA, including:
• There is no exception for distributions after separation from service that are made after age 55.
• The 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
FS 459-042 (6/1/2020)
of a spouse or former spouse).
• The exception for distributions 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.
• There are additional exceptions for (1) distributions for qualied higher education expenses, (2) distributions
up to $10,000 used in a qualied rst-time home purchase, and (3) distributions after you have received
unemployment compensation for 12 consecutive weeks (or would have been eligible to receive unemployment
compensation but for self-employed status).
Special rules and options
Will I owe state income taxes?
This notice does not describe any state or local income tax rules (including withholding rules).
If your distribution includes after-tax contributions
After-tax contributions included in a distribution are not taxed. If a distribution is only part of your benet, an
allocable portion of your after-tax contributions is generally included in the distribution. 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 distribution.
You may roll over to an IRA a distribution 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 distributions from the IRAs). If you do a direct
rollover of only a portion of the amount paid from PERS and a portion is paid to you, each of the distributions
will include an allocable portion of the after-tax contributions. If you do a 60-day rollover to an IRA of only a
portion of the distribution made to you, the after-tax contributions are treated as rolled over last. For example,
assume you are receiving a complete distribution of your benet which totals $12,000, of which $2,000 is after-
tax contributions. In this case, if you roll over $10,000 to an 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 distribution 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 distribution
that includes after-tax contributions, but only up to the amount of the distribution 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 distribution of a nonrefundable user fee.
For more information, see IRS Publication 590, Individual Retirement Arrangements (IRAs).
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 distribution 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 pension distribution is used to pay for health
coverage or qualied long-term care insurance
If you retired as a public safety ofcer and your retirement was by reason of disability or was after normal
retirement age, you can exclude from your taxable income distribution 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 ofcer is a
law enforcement ofcer, reghter, chaplain, or member of a rescue squad or ambulance crew.
Page 3 of 5
FS 459-042 (6/1/2020)
If you roll over your distribution to a Roth IRA
You can roll over a distribution made before January 1, 2010, to a Roth IRA only if your modied adjusted
gross income is not more than $100,000 for the year the distribution is made to you and, if married, you le a
joint return. These limitations do not apply to distributions made to you from PERS after 2009. If you wish to
roll over the distribution to a Roth IRA, but you are not eligible to do a rollover to a Roth IRA until after 2009,
you can do a rollover to a traditional IRA and then, after 2009, elect to convert the traditional IRA into a Roth
IRA.
If you roll over the distribution to a Roth IRA, a special rule applies under which the amount of the distribution
rolled over (reduced by any after-tax amounts) will be taxed. However, the 10 percent additional income tax on
early distributions will not apply (unless you take the amount rolled over out of the Roth IRA within ve years,
counting from January 1 of the year of the rollover). For PERS distributions during 2010 that are rolled over to
a Roth IRA, the taxable amount can be spread over a two-year period starting in 2011.
If you roll over the distribution to a Roth IRA, later distributions 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 distribution
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 ve years. In applying this ve-year rule, you count
from January 1 of the year for which your rst contribution was made to a Roth IRA. Distributions from the Roth
IRA that are not qualied distributions will be taxed to the extent of earnings after the rollover, including the 10
percent 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,
Individual Retirement Arrangements (IRAs). You cannot roll over a distribution from PERS to a designated Roth
account in an employer plan.
If you are not a plan participant
Distributions 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 percent additional income tax on early distributions and the special rules for public safety
of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 distribution from PERS 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. An IRA you treat
as your own is treated like any other IRA of yours, so that distributions made to you before you are age 59½
will be subject to the 10 percent 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 70 ½ (if born before
July 1, 1949) or age 72 (if born after June 30, 1949). If you treat the IRA as an inherited IRA, distributions
from the IRA will not be subject to the 10 percent 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 PERS, you will not have to start receiving required minimum distributions from the inherited IRA until
the year the participant would have been age 70 ½ (if born before July 1, 1949) or age 72 (if born after June 30,
1949).
If you are a surviving beneciary other than a spouse
If you receive a distribution from PERS 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.
Distributions from the inherited IRA will not be subject to the 10 percent additional income tax on early
distributions. You will have to receive required minimum distributions from the inherited IRA.
Page 4 of 5
FS 459-042 (6/1/2020)
Distributions under a qualied domestic relations order. If you are the spouse or former spouse of the
participant who receives a distribution from PERS 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 distribution
to your own IRA or an eligible employer plan that will accept it). Distributions under the QDRO will not be
subject to the 10 percent 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 percent, PERS is generally required to withhold 30 percent of the distribution 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 distribution is one in a series of distributions for less than 10 years, your choice whether to make a
direct rollover will apply to all later distributions in the series (unless you make a different choice for later
distributions).
If your distributions for the year are less than $200, PERS is not required to allow you to do a direct rollover and
is not required to withhold federal income taxes. However, you may do a 60-day rollover.
Unless you elect otherwise, a mandatory cashout of more than $1,000 will be directly rolled over to an IRA
chosen by PERS or the payer. A mandatory cashout is a distribution from PERS 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 a professional tax advisor before taking a distribution from PERS. Also, you can
nd more detailed information on the federal tax treatment of distributions from employer plans in
IRS Publication 575, Pension and Annuity Income
IRS Publication 590, Individual Retirement Arrangements (IRAs)
IRS Publication 571, Tax-Sheltered Annuity Plans (403(b) Plans)
These publications are available from a local IRS ofce, on the web at www.irs.gov, or by calling
800-TAX-FORM.
Page 5 of 5
Form W-9
(Rev. October 2018)
Department of the Treasury
Internal Revenue Service
Request for Taxpayer
Identification Number and Certification
Go to www.irs.gov/FormW9 for instructions and the latest information.
Give Form to the
requester. Do not
send to the IRS.
1
Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
2
Business name/disregarded entity name, if different from above
3
Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the
following seven boxes.
4
Exemptions (codes apply only to
certain entities, not individuals; see
instructions on page 3):
Individual/sole proprietor or
single-member LLC
C Corporation S Corporation Partnership Trust/estate
Exempt payee code (if any)
Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership)
Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check
LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is
another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that
is disregarded from the owner should check the appropriate box for the tax classification of its owner.
Other (see instructions)
Exemption from FATCA reporting
code (if any)
(Applies to accounts maintained outside the U.S.)
5
Address (number, street, and apt. or suite no.) See instructions. Requester’s name and address (optional)
6
City, state, and ZIP code
7
List account number(s) here (optional)
Part I Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid
backup withholding. For individuals, this is generally your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN, later.
Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and
Number To Give the Requester for guidelines on whose number to enter.
Social security number
or
Part II Certification
Under penalties of perjury, I certify that:
1.
The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
2.
I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding; and
3.
I am a U.S. citizen or other U.S. person (defined below); and
4.
The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because
you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid,
acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments
other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.
General Instructions
Section references are to the Internal Revenue Code unless otherwise
noted.
Future developments. For the latest information about developments
related to Form W-9 and its instructions, such as legislation enacted
after they were published, go to www.irs.gov/FormW9.
Purpose of Form
An individual or entity (Form W-9 requester) who is required to file an
information return with the IRS must obtain your correct taxpayer
identification number (TIN) which may be your social security number
(SSN), individual taxpayer identification number (ITIN), adoption
taxpayer identification number (ATIN), or employer identification number
(EIN), to report on an information return the amount paid to you, or other
amount reportable on an information return. Examples of information
returns include, but are not limited to, the following.
Form 1099-INT (interest earned or paid)
Form 1099-DIV (dividends, including those from stocks or mutual
funds)
Form 1099-MISC (various types of income, prizes, awards, or gross
proceeds)
Form 1099-B (stock or mutual fund sales and certain other
transactions by brokers)
Form 1099-S (proceeds from real estate transactions)
Form 1099-K (merchant card and third party network transactions)
Form 1098 (home mortgage interest), 1098-E (student loan interest),
1098-T (tuition)
Form 1099-C (canceled debt)
Form 1099-A (acquisition or abandonment of secured property)
Use Form W-9 only if you are a U.S. person (including a resident
alien), to provide your correct TIN.
If you do not return Form W-9 to the requester with a TIN, you might
be subject to backup withholding. See What is backup withholding,
later.
Cat. No. 10231X
Form
W-9 (Rev. 10-2018)
Sign
Here
Signature of
U.S. person
Date
Print or type.
See Specific Instructions on page 3.
Print Form
Clear Fields
Page
2
Form W-9 (Rev. 10-
2018)
By signing the filled-out form, you:
1.
Certify that the TIN you are giving is correct (or you are waiting for a
number to be issued),
2.
Certify that you are not subject to backup withholding, or
3.
Claim exemption from backup withholding if you are a U.S. exempt
payee. If applicable, you are also certifying that as a U.S. person, your
allocable share of any partnership income from a U.S. trade or business
is not subject to the withholding tax on foreign partners' share of
effectively connected income, and
4.
Certify that FATCA code(s) entered on this form (if any) indicating
that you are exempt from the FATCA reporting, is correct. See What is
FATCA reporting, later, for further information.
Note: If you are a U.S. person and a requester gives you a form other
than Form W-9 to request your TIN, you must use the requester’s form if
it is substantially similar to this Form W-9.
Definition of a U.S. person. For federal tax purposes, you are
considered a U.S. person if you are:
An individual who is a U.S. citizen or U.S. resident alien;
A partnership, corporation, company, or association created or
organized in the United States or under the laws of the United States;
An estate (other than a foreign estate); or
A domestic trust (as defined in Regulations section 301.7701-7).
Special rules for partnerships. Partnerships that conduct a trade or
business in the United States are generally required to pay a withholding
tax under section 1446 on any foreign partners’ share of effectively
connected taxable income from such business. Further, in certain cases
where a Form W-9 has not been received, the rules under section 1446
require a partnership to presume that a partner is a foreign person, and
pay the section 1446 withholding tax. Therefore, if you are a U.S. person
that is a partner in a partnership conducting a trade or business in the
United States, provide Form W-9 to the partnership to establish your
U.S. status and avoid section 1446 withholding on your share of
partnership income.
In the cases below, the following person must give Form W-9 to the
partnership for purposes of establishing its U.S. status and avoiding
withholding on its allocable share of net income from the partnership
conducting a trade or business in the United States.
In the case of a disregarded entity with a U.S. owner, the U.S. owner
of the disregarded entity and not the entity;
In the case of a grantor trust with a U.S. grantor or other U.S. owner,
generally, the U.S. grantor or other U.S. owner of the grantor trust and
not the trust; and
In the case of a U.S. trust (other than a grantor trust), the U.S. trust
(other than a grantor trust) and not the beneficiaries of the trust.
Foreign person. If you are a foreign person or the U.S. branch of a
foreign bank that has elected to be treated as a U.S. person, do not use
Form W-9. Instead, use the appropriate Form W-8 or Form 8233 (see
Pub. 515, Withholding of Tax on Nonresident Aliens and Foreign
Entities).
Nonresident alien who becomes a resident alien. Generally, only a
nonresident alien individual may use the terms of a tax treaty to reduce
or eliminate U.S. tax on certain types of income. However, most tax
treaties contain a provision known as a “saving clause.” Exceptions
specified in the saving clause may permit an exemption from tax to
continue for certain types of income even after the payee has otherwise
become a U.S. resident alien for tax purposes.
If you are a U.S. resident alien who is relying on an exception
contained in the saving clause of a tax treaty to claim an exemption
from U.S. tax on certain types of income, you must attach a statement
to Form W-9 that specifies the following five items.
1.
The treaty country. Generally, this must be the same treaty under
which you claimed exemption from tax as a nonresident alien.
2.
The treaty article addressing the income.
3.
The article number (or location) in the tax treaty that contains the
saving clause and its exceptions.
4.
The type and amount of income that qualifies for the exemption
from tax.
5.
Sufficient facts to justify the exemption from tax under the terms of
the treaty article.
Example. Article 20 of the U.S.-China income tax treaty allows an
exemption from tax for scholarship income received by a Chinese
student temporarily present in the United States. Under U.S. law, this
student will become a resident alien for tax purposes if his or her stay in
the United States exceeds 5 calendar years. However, paragraph 2 of
the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows
the provisions of Article 20 to continue to apply even after the Chinese
student becomes a resident alien of the United States. A Chinese
student who qualifies for this exception (under paragraph 2 of the first
protocol) and is relying on this exception to claim an exemption from tax
on his or her scholarship or fellowship income would attach to Form
W-9 a statement that includes the information described above to
support that exemption.
If you are a nonresident alien or a foreign entity, give the requester the
appropriate completed Form W-8 or Form 8233.
Backup Withholding
What is backup withholding? Persons making certain payments to you
must under certain conditions withhold and pay to the IRS 24% of such
payments. This is called “backup withholding.” Payments that may be
subject to backup withholding include interest, tax-exempt interest,
dividends, broker and barter exchange transactions, rents, royalties,
nonemployee pay, payments made in settlement of payment card and
third party network transactions, and certain payments from fishing boat
operators. Real estate transactions are not subject to backup
withholding.
You will not be subject to backup withholding on payments you
receive if you give the requester your correct TIN, make the proper
certifications, and report all your taxable interest and dividends on your
tax return.
Payments you receive will be subject to backup withholding if:
1.
You do not furnish your TIN to the requester,
2.
You do not certify your TIN when required (see the instructions for
Part II for details),
3.
The IRS tells the requester that you furnished an incorrect TIN,
4.
The IRS tells you that you are subject to backup withholding
because you did not report all your interest and dividends on your tax
return (for reportable interest and dividends only), or
5.
You do not certify to the requester that you are not subject to
backup withholding under 4 above (for reportable interest and dividend
accounts opened after 1983 only).
Certain payees and payments are exempt from backup withholding.
See Exempt payee code, later, and the separate Instructions for the
Requester of Form W-9 for more information.
Also see Special rules for partnerships, earlier.
What is FATCA Reporting?
The Foreign Account Tax Compliance Act (FATCA) requires a
participating foreign financial institution to report all United States
account holders that are specified United States persons. Certain
payees are exempt from FATCA reporting. See Exemption from FATCA
reporting code, later, and the Instructions for the Requester of Form
W-9 for
more information.
Updating Your Information
You must provide updated information to any person to whom you
claimed to be an exempt payee if you are no longer an exempt payee
and anticipate receiving reportable payments in the future from this
person. For example, you may need to provide updated information if
you are a C corporation that elects to be an S corporation, or if you no
longer are tax exempt. In addition, you must furnish a new Form W-9 if
the name or TIN changes for the account; for example, if the grantor of a
grantor trust dies.
Penalties
Failure to furnish TIN. If you fail to furnish your correct TIN to a
requester, you are subject to a penalty of $50 for each such failure
unless your failure is due to reasonable cause and not to willful neglect.
Civil penalty for false information with respect to withholding. If you
make a false statement with no reasonable basis that results in no
backup withholding, you are subject to a $500 penalty.
Page
3
Form W-9 (Rev. 10-
2018)
Criminal penalty for falsifying information. Willfully falsifying
certifications or affirmations may subject you to criminal penalties
including fines and/or imprisonment.
Misuse of TINs. If the requester discloses or uses TINs in violation of
federal law, the requester may be subject to civil and criminal penalties.
Specific Instructions
Line 1
You must enter one of the following on this line; do not leave this line
blank. The name should match the name on your tax return.
If this Form W-9 is for a joint account (other than an account
maintained by a foreign financial institution (FFI)), list first, and then
circle, the name of the person or entity whose number you entered in
Part I of Form W-9. If you are providing Form W-9 to an FFI to document
a joint account, each holder of the account that is a U.S. person must
provide a Form W-9.
a.
Individual. Generally, enter the name shown on your tax return. If
you have changed your last name without informing the Social Security
Administration (SSA) of the name change, enter your first name, the last
name as shown on your social security card, and your new last name.
Note: ITIN applicant: Enter your individual name as it was entered on
your Form W-7 application, line 1a. This should also be the same as the
name you entered on the Form 1040/1040A/1040EZ you filed with your
application.
b.
Sole proprietor or single-member LLC. Enter your individual
name as shown on your 1040/1040A/1040EZ on line 1. You may enter
your business, trade, or “doing business as” (DBA) name on line 2.
c.
Partnership, LLC that is not a single-member LLC, C
corporation, or S corporation. Enter the entity's name as shown on the
entity's tax return on line 1 and any business, trade, or DBA name on
line 2.
d.
Other entities. Enter your name as shown on required U.S. federal
tax documents on line 1. This name should match the name shown on the
charter or other legal document creating the entity. You may enter any
business, trade, or DBA name on line 2.
e.
Disregarded entity. For U.S. federal tax purposes, an entity that is
disregarded as an entity separate from its owner is treated as a
“disregarded entity.” See Regulations section 301.7701-2(c)(2)(iii). Enter
the owner's name on line 1. The name of the entity entered on line 1
should never be a disregarded entity. The name on line 1 should be the
name shown on the income tax return on which the income should be
reported. For example, if a foreign LLC that is treated as a disregarded
entity for U.S. federal tax purposes has a single owner that is a U.S.
person, the U.S. owner's name is required to be provided on line 1. If
the direct owner of the entity is also a disregarded entity, enter the first
owner that is not disregarded for federal tax purposes. Enter the
disregarded entity's name on line 2, “Business name/disregarded entity
name.” If the owner of the disregarded entity is a foreign person, the
owner must complete an appropriate Form W-8 instead of a Form W-9.
This is the case even if the foreign person has a U.S. TIN.
Line 2
If you have a business name, trade name, DBA name, or disregarded
entity name, you may enter it on line 2.
Line 3
Check the appropriate box on line 3 for the U.S. federal tax
classification of the person whose name is entered on line 1. Check only
one box on line 3.
IF the entity/person on line 1 is
a(n) . . .
THEN check the box for . . .
Corporation Corporation
Individual
Sole proprietorship, or
Single-member limited liability
company (LLC) owned by an
individual and disregarded for U.S.
federal tax purposes.
Individual/sole proprietor or single-
member LLC
LLC treated as a partnership for
U.S. federal tax purposes,
LLC that has filed Form 8832 or
2553 to be taxed as a corporation,
or
LLC that is disregarded as an
entity separate from its owner but
the owner is another LLC that is
not disregarded for U.S. federal tax
purposes.
Limited liability company and enter
the appropriate tax classification.
(P= Partnership; C= C corporation;
or S= S corporation)
Partnership Partnership
Trust/estate
Trust/estate
Line 4, Exemptions
If you are exempt from backup withholding and/or FATCA reporting,
enter in the appropriate space on line 4 any code(s) that may apply to
you.
Exempt payee code.
Generally, individuals (including sole proprietors) are not exempt from
backup withholding.
Except as provided below, corporations are exempt from backup
withholding for certain payments, including interest and dividends.
Corporations are not exempt from backup withholding for payments
made in settlement of payment card or third party network transactions.
Corporations are not exempt from backup withholding with respect to
attorneys’ fees or gross proceeds paid to attorneys, and corporations
that provide medical or health care services are not exempt with respect
to payments reportable on Form 1099-MISC.
The following codes identify payees that are exempt from backup
withholding. Enter the appropriate code in the space in line 4.
1—An organization exempt from tax under section 501(a), any IRA, or
a custodial account under section 403(b)(7) if the account satisfies the
requirements of section 401(f)(2)
2—The United States or any of its agencies or instrumentalities
3—A state, the District of Columbia, a U.S. commonwealth or
possession, or any of their political subdivisions or instrumentalities
4—A foreign government or any of its political subdivisions, agencies,
or instrumentalities
5—A corporation
6—A dealer in securities or commodities required to register in the
United States, the District of Columbia, or a U.S. commonwealth or
possession
7—A futures commission merchant registered with the Commodity
Futures Trading Commission
8—A real estate investment trust
9—An entity registered at all times during the tax year under the
Investment Company Act of 1940
10—A common trust fund operated by a bank under section 584(a)
11—A financial institution
12—A middleman known in the investment community as a nominee or
custodian
13—A trust exempt from tax under section 664 or described in section
4947
Page
4
Form W-9 (Rev. 10-
2018)
The following chart shows types of payments that may be exempt
from backup withholding. The chart applies to the exempt payees listed
above, 1 through 13.
IF the payment is for . . .
THEN the payment is exempt
for . . .
Interest and dividend payments
All exempt payees except
for 7
Broker transactions
Exempt payees 1 through 4 and 6
through 11 and all C corporations.
S corporations must not enter an
exempt payee code because they
are exempt only for sales of
noncovered securities acquired
prior to 2012.
Barter exchange transactions and
patronage dividends
Exempt payees 1 through 4
Payments over $600 required to be
reported and direct sales over
$5,000
1
Generally, exempt payees
1 through 5
2
Payments made in settlement of
payment card or third party network
transactions
Exempt payees 1 through 4
1
See Form 1099-MISC, Miscellaneous Income, and its instructions.
2
However, the following payments made to a corporation and
reportable on Form 1099-MISC are not exempt from backup
withholding: medical and health care payments, attorneys’ fees, gross
proceeds paid to an attorney reportable under section 6045(f), and
payments for services paid by a federal executive agency.
Exemption from FATCA reporting code. The following codes identify
payees that are exempt from reporting under FATCA. These codes
apply to persons submitting this form for accounts maintained outside
of the United States by certain foreign financial institutions. Therefore, if
you are only submitting this form for an account you hold in the United
States, you may leave this field blank. Consult with the person
requesting this form if you are uncertain if the financial institution is
subject to these requirements. A requester may indicate that a code is
not required by providing you with a Form W-9 with “Not Applicable” (or
any similar indication) written or printed on the line for a FATCA
exemption code.
A—An organization exempt from tax under section 501(a) or any
individual retirement plan as defined in section 7701(a)(37)
B—The United States or any of its agencies or instrumentalities
C—A state, the District of Columbia, a U.S. commonwealth or
possession, or any of their political subdivisions or instrumentalities
D—A corporation the stock of which is regularly traded on one or
more established securities markets, as described in Regulations
section 1.1472-1(c)(1)(i)
E—A corporation that is a member of the same expanded affiliated
group as a corporation described in Regulations section 1.1472-1(c)(1)(i)
F—A dealer in securities, commodities, or derivative financial
instruments (including notional principal contracts, futures, forwards,
and options) that is registered as such under the laws of the United
States or any state
G—A real estate investment trust
H—A regulated investment company as defined in section 851 or an
entity registered at all times during the tax year under the Investment
Company Act of 1940
I—A common trust fund as defined in section 584(a) J—
A bank as defined in section 581
K—A broker
L—A trust exempt from tax under section 664 or described in section
4947(a)(1)
M—A tax exempt trust under a section 403(b) plan or section 457(g)
plan
Note: You may wish to consult with the financial institution requesting
this form to determine whether the FATCA code and/or exempt payee
code should be completed.
Line 5
Enter your address (number, street, and apartment or suite number).
This is where the requester of this Form W-9 will mail your information
returns. If this address differs from the one the requester already has on
file, write NEW at the top. If a new address is provided, there is still a
chance the old address will be used until the payor changes your
address in their records.
Line 6
Enter your city, state, and ZIP code.
Part I. Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. If you are a resident alien and
you do not have and are not eligible to get an SSN, your TIN is your IRS
individual taxpayer identification number (ITIN). Enter it in the social
security number box. If you do not have an ITIN, see How to get a TIN
below.
If you are a sole proprietor and you have an EIN, you may enter either
your SSN or EIN.
If you are a single-member LLC that is disregarded as an entity
separate from its owner, enter the owner’s SSN (or EIN, if the owner has
one). Do not enter the disregarded entity’s EIN. If the LLC is classified as
a corporation or partnership, enter the entity’s EIN.
Note: See What Name and Number To Give the Requester, later, for
further clarification of name and TIN combinations.
How to get a TIN. If you do not have a TIN, apply for one immediately.
To apply for an SSN, get Form SS-5, Application for a Social Security
Card, from your local SSA office or get this form online at
www.SSA.gov. You may also get this form by calling 1-800-772-1213.
Use Form W-7, Application for IRS Individual Taxpayer Identification
Number, to apply for an ITIN, or Form SS-4, Application for Employer
Identification Number, to apply for an EIN. You can apply for an EIN
online by accessing the IRS website at www.irs.gov/Businesses and
clicking on Employer Identification Number (EIN) under Starting a
Business. Go to www.irs.gov/Forms to view, download, or print Form W-
7 and/or Form SS-4. Or, you can go to www.irs.gov/OrderForms to
place an order and have Form W-7 and/or SS-4 mailed to you within 10
business days.
If you are asked to complete Form W-9 but do not have a TIN, apply
for a TIN and write “Applied For” in the space for the TIN, sign and date
the form, and give it to the requester. For interest and dividend
payments, and certain payments made with respect to readily tradable
instruments, generally you will have 60 days to get a TIN and give it to
the requester before you are subject to backup withholding on
payments. The 60-day rule does not apply to other types of payments.
You will be subject to backup withholding on all such payments until
you provide your TIN to the requester.
Note: Entering “Applied For” means that you have already applied for a
TIN or that you intend to apply for one soon.
Caution: A disregarded U.S. entity that has a foreign owner must use
the appropriate Form W-8.
Part II. Certification
To establish to the withholding agent that you are a U.S. person, or
resident alien, sign Form W-9. You may be requested to sign by the
withholding agent even if item 1, 4, or 5 below indicates otherwise.
For a joint account, only the person whose TIN is shown in Part I
should sign (when required). In the case of a disregarded entity, the
person identified on line 1 must sign. Exempt payees, see Exempt payee
code, earlier.
Signature requirements. Complete the certification as indicated in
items 1 through 5 below.
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Form W-9 (Rev. 10-
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1.
Interest, dividend, and barter exchange accounts opened
before 1984 and broker accounts considered active during 1983.
You must give your correct TIN, but you do not have to sign the
certification.
2.
Interest, dividend, broker, and barter exchange accounts
opened after 1983 and broker accounts considered inactive during
1983. You must sign the certification or backup withholding will apply. If
you are subject to backup withholding and you are merely providing
your correct TIN to the requester, you must cross out item 2 in the
certification before signing the form.
3.
Real estate transactions. You must sign the certification. You may
cross out item 2 of the certification.
4.
Other payments. You must give your correct TIN, but you do not
have to sign the certification unless you have been notified that you
have previously given an incorrect TIN. “Other payments” include
payments made in the course of the requester’s trade or business for
rents, royalties, goods (other than bills for merchandise), medical and
health care services (including payments to corporations), payments to
a nonemployee for services, payments made in settlement of payment
card and third party network transactions, payments to certain fishing
boat crew members and fishermen, and gross proceeds paid to
attorneys (including payments to corporations).
5.
Mortgage interest paid by you, acquisition or abandonment of
secured property, cancellation of debt, qualified tuition program
payments (under section 529), ABLE accounts (under section 529A),
IRA, Coverdell ESA, Archer MSA or HSA contributions or
distributions, and pension distributions. You must give your correct
TIN, but you do not have to sign the certification.
What Name and Number To Give the Requester
For this type of account:
Give name and EIN of:
14. Account with the Department of
Agriculture in the name of a public
entity (such as a state or local
government, school district, or
prison) that receives agricultural
program payments
The public entity
15. Grantor trust filing under the Form
1041 Filing Method or the Optional
Form 1099 Filing Method 2 (see
Regulations section 1.671-4(b)(2)(i)(B))
The trust
1
List first and circle the name of the person whose number you furnish.
If only one person on a joint account has an SSN, that person’s number
must be furnished.
2
Circle the minor’s name and furnish the minor’s SSN.
3
You must show your individual name and you may also enter your
business or DBA name on the “Business name/disregarded entity”
name line. You may use either your SSN or EIN (if you have one), but the
IRS encourages you to use your SSN.
4
List first and circle the name of the trust, estate, or pension trust. (Do
not furnish the TIN of the personal representative or trustee unless the
legal entity itself is not designated in the account title.) Also see Special
rules for partnerships, earlier.
*Note: The grantor also must provide a Form W-9 to trustee of trust.
Note: If no name is circled when more than one name is listed, the
number will be considered to be that of the first name listed.
Secure Your Tax Records From Identity Theft
Identity theft occurs when someone uses your personal information
such as your name, SSN, or other identifying information, without your
permission, to commit fraud or other crimes. An identity thief may use
your SSN to get a job or may file a tax return using your SSN to receive
a refund.
To reduce your risk:
Protect your SSN,
Ensure your employer is protecting your SSN, and
Be careful when choosing a tax preparer.
If your tax records are affected by identity theft and you receive a
notice from the IRS, respond right away to the name and phone number
printed on the IRS notice or letter.
If your tax records are not currently affected by identity theft but you
think you are at risk due to a lost or stolen purse or wallet, questionable
credit card activity or credit report, contact the IRS Identity Theft Hotline
at 1-800-908-4490 or submit Form 14039.
For more information, see Pub. 5027, Identity Theft Information for
Taxpayers.
Victims of identity theft who are experiencing economic harm or a
systemic problem, or are seeking help in resolving tax problems that
have not been resolved through normal channels, may be eligible for
Taxpayer Advocate Service (TAS) assistance. You can reach TAS by
calling the TAS toll-free case intake line at 1-877-777-4778 or TTY/TDD
1-800-829-4059.
Protect yourself from suspicious emails or phishing schemes.
Phishing is the creation and use of email and websites designed to
mimic legitimate business emails and websites. The most common act
is sending an email to a user falsely claiming to be an established
legitimate enterprise in an attempt to scam the user into surrendering
private information that will be used for identity theft.
For this type of account:
Give name and SSN of:
1. Individual
The individual
2. Two or more individuals (joint
account) other than an account
maintained by an FFI
The actual owner of the account or, if
combined funds, the first individual on
the account
1
3. Two or more U.S. persons
(joint account maintained by an FFI)
Each holder of the account
4. Custodial account of a minor
(Uniform Gift to Minors Act)
The minor
2
5. a. The usual revocable savings trust
(grantor is also trustee)
b. So-called trust account that is not
a legal or valid trust under state law
The grantor-trustee
1
The actual owner
1
6. Sole proprietorship or disregarded
entity owned by an individual
The owner
3
7. Grantor trust filing under Optional
Form 1099 Filing Method 1 (see
Regulations section 1.671-4(b)(2)(i)
(A))
The grantor*
For this type of account:
Give name and EIN of:
8. Disregarded entity not owned by an
individual
The owner
9. A valid trust, estate, or pension trust
Legal entity
4
10. Corporation or LLC electing
corporate status on Form 8832 or
Form 2553
The corporation
11. Association, club, religious,
charitable, educational, or other tax-
exempt organization
The organization
12. Partnership or multi-member LLC
The partnership
13. A broker or registered nominee The broker or nominee
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Form W-9 (Rev. 10-
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The IRS does not initiate contacts with taxpayers via emails. Also, the
IRS does not request personal detailed information through email or ask
taxpayers for the PIN numbers, passwords, or similar secret access
information for their credit card, bank, or other financial accounts.
If you receive an unsolicited email claiming to be from the IRS,
forward this message to phishing@irs.gov. You may also report misuse
of the IRS name, logo, or other IRS property to the Treasury Inspector
General for Tax Administration (TIGTA) at 1-800-366-4484. You can
forward suspicious emails to the Federal Trade Commission at
spam@uce.gov or report them at www.ftc.gov/complaint. You can
contact the FTC at www.ftc.gov/idtheft or 877-IDTHEFT (877-438-4338).
If you have been the victim of identity theft, see www.IdentityTheft.gov
and Pub. 5027.
Visit www.irs.gov/IdentityTheft to learn more about identity theft and
how to reduce your risk.
Privacy Act Notice
Section 6109 of the Internal Revenue Code requires you to provide your
correct TIN to persons (including federal agencies) who are required to
file information returns with the IRS to report interest, dividends, or
certain other income paid to you; mortgage interest you paid; the
acquisition or abandonment of secured property; the cancellation of
debt; or contributions you made to an IRA, Archer MSA, or HSA. The
person collecting this form uses the information on the form to file
information returns with the IRS, reporting the above information.
Routine uses of this information include giving it to the Department of
Justice for civil and criminal litigation and to cities, states, the District of
Columbia, and U.S. commonwealths and possessions for use in
administering their laws. The information also may be disclosed to other
countries under a treaty, to federal and state agencies to enforce civil
and criminal laws, or to federal law enforcement and intelligence
agencies to combat terrorism. You must provide your TIN whether or
not you are required to file a tax return. Under section 3406, payers
must generally withhold a percentage of taxable interest, dividend, and
certain other payments to a payee who does not give a TIN to the payer.
Certain penalties may also apply for providing false or fraudulent
information.