PUBLIC EMPLOYEE RETIREMENT ADMINISTRATION COMMISSION
Application for Withdrawal of Accumulated Total Deductions (Refund Form) 4
Member Last Name:
First Name: SSN: ***-**-__ __ __ __
Section C: Method of Payment
Statements Regarding Tax Consequences
I have initialed the statements below to indicate that I agree with them:
• I understand that my accumulated total deductions may have both a taxable and non-taxable
component, due to changes in the law which took effect in 1988.
• If I began service in 1988 or after, it is unlikely that any portion of my accumulated total deductions will not
be subject to federal tax withholding.
• 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.
• If I choose to directly received the return of my accumulated total deductions and I am under age 59½, I may
be subject to a further tax penalty.
Select one box for the "Taxable Portion" and, if it applies to you, one box for the "Non-Taxable Portion" on the next page.
1. Direct Rollover
2. Paid directly to me. 20% will be withheld for federal taxes and remitted to the Internal Revenue Service.
3. Partial Direct Rollover in the amount of
of the balance or
The remaining balance will be paid directly to me, less 20% federal tax withholding,
which will be remitted to the Internal Revenue Service.
Account Information for Rollover:
Name of eligible 401(a) Plan, 403(b) Plan, Governmental 457(b) Retirement Plan, IRA, Roth IRA, or SIMPLE IRA*
Address of above-listed entity City State Zip Code
Member's Account Number with above-listed entity
Member's Address City State Zip Code
Is this Account a SIMPLE IRA?
If YES, has has the account been established for at least two years?
* After a two-year wating period, SIMPLE IRA accounts can receive rollover eligible funds from other types of retirement
plans, including 401(a) governmental plans. The two-year period begins on the first day on which the employer
deposits contributions in the SIMPLE IRA.