Fillable Rev. 05/2010 (Port of Richmond)

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Rev. 05/2010 (Port of Richmond)

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Rev. 05/2010
REQUEST FOR REFUND OF
DEFINED BENEFIT PLAN CONTRIBUTIONS
please type or print in ink
Note: Requests received by the 15th of the month will processed in the current month. Requests received after the 15th of the month will be
processed in the following month.
PART A: MEMBER INFORMATION
State:
I elect to receive payment of my refund of retirement contributions via direct rollover, paid directly from the System to the custodian
of an eligible retirement plan as defined in Section 401(a), 401(k), 403(b) or 457 of the Internal Revenue Service Code, a traditional
individual retirement account (IRA) or an individual retirement annuity. (NOTE: Rollover instructions must be provided by the
qualified plan.) All post-tax contributions will be refunded to you and are not subject to tax withholding.
PART B: PAYMENT ELECTION (choose one)
Zip:
City:
Member's Signature:
Date:
PART D: NOTARY
Name:
I elect to receive payment of my refund of retirement contributions in a lump sum, less all applicable federal and state withholding
taxes. (See the attached "Special Tax Notice Regarding Plan Payments.") All post-tax contributions will be refunded to you and are
not subject to tax withholding.
Birth Date:
SSN:
Address:
Department:
o
o
I hereby certify that: 1) I am a former employee of a participating employer who has paid contributions to the System; 2) I have read and
understand the information provided with this form; 3) I understand that if I elect to receive a lump sum payment, a 20% federal tax and
4% state tax will be withheld from the taxable portion of my refund; and I may be subject to an additional 10% federal tax penalty ; and 4)
I have selected the payout of funds as shown above and understand I am no longer eligible for future retirement benefits from the
Richmond Retirement System.
PART C: AUTHORIZATION
Position:
Termination Date:
Employment Date:
Contributions Amount:
Interest Amount:
My commission expires:
The individual whose name is signed above appeared before me, acknowledged the signature to be his/her, and having been duly
sworn by me, made an oath that the statements are true.
To be completed by Notary or by other Court Official authorized to take acknowledgements:
Notary Registration Number:
State of:
on:
Notary Public:
1st Review:
Date:
2nd Review
Date:
RRS USE ONLY
20
Check#:
Check Date:
900 East Broad Street
Room 400
Richmond, VA 23219
RICHMOND RETIREMENT SYSTEM
www.richmondgov.com/retirement
Phone 804.646.5958
Fax 804.646.5299
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Rev. 052010 (Port of Richmond)

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Completed 1 November 2020

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