ICMA-RC • Attn: Workow Management Team • P.O. Box 96220 • Washington, DC 20090-6220 • Toll Free 800-669-7400 • www.icmarc.org • Fax 202-682-6439 46987-0420-CRD20NOER | 1
Please follow the steps shown below to ensure we are able to process your request in a timely manner. This form is used to request a one-time
payment from your Governmental 401 Plan or 457 Deferred Compensation Plan account for a Coronavirus Related Distribution. For all other
withdrawal requests, please log in to Account Access at www.icmarc.org/login or contact ICMA-RC for the appropriate forms.
Coronavirus Related Distributions are not available in all plans. Please check with your employer or ICMA-RC to conrm
eligibility. Additional conditions may apply if you are requesting a withdrawal from a 401(a) Money Purchase Plan.
1. Complete the Self-Certication Form and Coronavirus Related Distribution Withdrawal Form.
2. Fax or mail the completed form to ICMA-RC.
Fax: ICMA-RC
ATTN: Workow Management Team
202-682-6439
Mail: ICMA-RC
ATTN: Workow Management Team
P.O. Box 96220
Washington, DC 20090-6220
Please keep a copy of the completed form for your records.
TIME FRAME FOR PAYMENTS
Following the receipt of your properly completed withdrawal form, payments will be distributed as soon as possible (typically
within three business days). Please submit your request at least a few days in advance of your desired payment date.
At ICMA-RC, we take security of our participants retirement assets seriously. We have security measures in place and
we continuously apply enhancements to safeguard your assets.
Additional care is taken regarding the security of your account when processing withdrawal requests. Adding
or changing information regarding personally identiable information on le with ICMA-RC may delay your
withdrawal.
EMAIL CONFIRMATIONS
ICMA-RC is now sending many conrmation notices via email, including conrmations related to your withdrawal requests.
Please be sure to provide your email address in section 1 of the form.
WITHDRAWAL FORM (DIRECT)
Coronavirus Related Distribution
ICMA-RC • Attn: Workow Management Team • P.O. Box 96220 • Washington, DC 20090-6220 • Toll Free 800-669-7400 • www.icmarc.org • Fax 202-682-6439 46987-0420-CRD20NOER | 2
I, _______________________________ (participant name), have requested a Coronavirus Related Distribution from the __________________________
____________ (plan name), ______________ (plan number).
To be eligible for the Coronavirus Related Distribution, I hereby certify that I meet one of the following criteria:
• I have been diagnosed with the virus SARS-CoV-2 or with coronavirus disease 2019 (COVID-19) by a test approved by the Centers for Disease Control and Prevention.
• My spouse or dependent (as dened in Internal Revenue Code section 152) is diagnosed with such virus or disease.
• I have experienced adverse nancial consequences as a result of being quarantined, furloughed, laid off, having work hours reduced due to such virus or disease,
being unable to work due to lack of child care due to such virus or disease, or other factors as determined by the Secretary of the Treasury.
If the plan identied above is a 401(a) Money Purchase Plan, I certify that I also meet the requirements for an in-service withdrawal under the plan if I am currently employed
by the plan sponsor of this plan.
I make this certication on this day, / / (MM/DD/YYYY)
Signature: _____________________________________________
Printed Name: ___________________________________________
Return this form along with the distribution request to ICMA-RC for processing.
Employee Certication
Coronavirus Related Distribution Eligibility
click to sign
signature
click to edit
ICMA-RC • Attn: Workow Management Team • P.O. Box 96220 • Washington, DC 20090-6220 • Toll Free 800-669-7400 • www.icmarc.org • Fax 202-682-6439 46987-0420-CRD20NOER | 3
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ICMA-RC • Attn: Workow Management Team • P.O. Box 96220 • Washington, DC 20090-6220 • Toll Free 800-669-7400 • www.icmarc.org • Fax 202-682-6439 46987-0420-CRD20NOER | 4
1. Submit this form to request a Coronavirus Related Distribution from your Governmental 401 Plan or 457 Deferred Compensation Plan account. These withdrawals are not available in all
plans. Please check with your employer or ICMA-RC to conrm eligibility.
2. Return the completed form to ICMA-RC. Missing or incomplete information will result in delays.
PARTICIPANT INFORMATION (COMPLETE ALL FIELDS IN THIS SECTION)
1
Social Security Number:
Zip Code:
State:
Employer Plan Number:
Employer Plan Name:
Mailing Address:
Email Address:
City
Date of Birth: (MM/DD/YYYY)
/ /
Preferred Phone Number:
( )
Full Name of Participant:
Last First
M.I.
REQUEST TYPE (SELECT ONE OPTION ONLY)
2
Coronavirus Related Distribution
In-service (currently working)
(Please Note: For 401(a) Money Purchase Plans, you must meet applicable requirements; please check with your employer to verify the type of plan you have and applicable
requirements.)
Lump Sum (separation from employment)
PAYMENT AMOUNT
3
A check for the amount specied, reduced by applicable tax withholding, will be sent to your current mailing address.
Payment Amount: $
(Which may be up to the maximum amount your plan sponsor allows, not to exceed $100,000.)
Note: Maximum amount includes amounts withdrawn from all retirement plan accounts you may own.
Taxable amounts will be reported on a Form 1099-R, which will be sent to you in January 2021.
PARTICIPANT SIGNATURE
5
I acknowledge I have received and signed the Coronavirus Related Distribution self-certication form. I direct ICMA-RC to process the payment request indicated above. I certify that the
Social Security Number (Taxpayer Identication Number) I provided is correct.
Signature:
Date: / /
PARTICIPANT SEPARATION FROM SERVICE DATE (IF APPLICABLE)
6
Date: / /
WITHDRAWAL FORM (DIRECT)
Coronavirus Related Distribution
TAXATION AND WITHHOLDING REQUIREMENTS
4
If you do not provide withholding instructions, 10% will be withheld for federal income taxes as a default. The state tax will be withheld per state requirements.
a. Withhold FEDERAL income tax at the rate of _______% OR
No withholding
b. Withhold STATE income tax at the rate of _______% OR Requirement per State
ICMA-RC • Attn: Workow Management Team • P.O. Box 96220 • Washington, DC 20090-6220 • Toll Free 800-669-7400 • www.icmarc.org • Fax 202-682-6439 46987-0420-CRD20NOER | 5
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ICMA-RC • Attn: Workow Management Team • P.O. Box 96220 • Washington, DC 20090-6220 • Toll Free 800-669-7400 • www.icmarc.org • Fax 202-682-6439 46987-0420-CRD20NOER | 6
Beneciary Designations
ICMA-RC recommends that you conrm that we have current
beneciary information. Please review and update your beneciary
information as appropriate by accessing your account online at
www.icmarc.org/login.
Federal Tax Withholding
e CARES Act does not require a mandatory 20% federal income
tax withholding be applied to any qualifying coronavirus-related
distributions. If no withholding option is selected in Section 4 of the
form, however, ICMA-RC will default to 10% federal withholding.
Note: With the exception of withdrawals from an after-tax
contribution account.
Non U.S. Citizens: Generally, individuals who are not U.S. citizens
and residing outside of the United States are subject to 30% federal tax
withholding. A reduced rate, including exemption, may apply if there is a
tax treaty between your country of residence and the United States.
State Tax Withholding
Several states have mandatory tax withholding requirements. ICMA-RC
automatically withholds taxes for states which require withholding from
retirement plan withdrawals and will honor requests for withholding in
other states. Income taxation of payments from retirement plans varies
from state-to-state. You should seek state tax advice from the appropriate
state department of revenue if you have questions regarding state tax
withholding requirements.
You may request federal and state tax withholding percentages that dier
from those described above by completing the Tax Withholding Change
Form. is form is available online at www.icmarc.org/forms or by
contacting ICMA-RC.
Tax Reporting
Taxable amounts will be reported on a Form 1099-R, which will be sent
to you in January 2021.
New Optional Coronavirus-Related Distribution (CRD):
Code Section 72(t), which applies an additional 10% tax on early
withdrawals, is waived for withdrawals up to $100,000 across all
retirement plans or IRAs for a qualied participant.
ose individuals may prorate the payment of applicable taxes on
the income from the withdrawal over a three-year period.
e withdrawal amount may be paid tax-free back to the plan over
the next three years.
Repayments of these withdrawals would not be subject to the
retirement plan contribution limits.
Note: For in-service withdrawal requests, 401(a) Money Purchase Plans
have unique requirements. Please check with your employer to make
sure you are meeting applicable requirements.
VT Retirement IncomeAdvantage Fund
If your plan oers the VT Retirement IncomeAdvantage Fund (the
Fund), any assets you have invested in the Fund will be excluded from
your withdrawal request. If you would like to initiate withdrawals from
the Fund, please contact ICMA-RC for the appropriate withdrawal
forms.
You can transfer assets from the Fund to other investment options
available in your plan if you would like to have them distributed with
your withdrawal request. However, you should be aware that withdrawals
from the Fund prior to Lock-In proportionately reduce guaranteed
values.
After Lock-In, Excess Withdrawals will proportionately reduce and
potentially terminate available guarantees. For additional information,
please review the VT Retirement IncomeAdvantage Fund Important
Considerations document.
VantageBroker
If your plan oers VantageBroker, any assets you have invested in
VantageBroker will be excluded from your withdrawal request. In order
to withdraw funds from your brokerage account, you must rst transfer
the assets back to your core account at ICMA-RC. You can liquidate
assets in your brokerage account and transfer the assets back to your
core account online. Settlement of the sale of investments held in your
brokerage account may take up to three business days.
ADDITIONAL INFORMATION
ICMA-RC • Attn: Workow Management Team • P.O. Box 96220 • Washington, DC 20090-6220 • Toll Free 800-669-7400 • www.icmarc.org • Fax 202-682-6439 46987-0420-CRD20NOER | 7
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ICMA-RC • Attn: Workow Management Team • P.O. Box 96220 • Washington, DC 20090-6220 • Toll Free 800-669-7400 • www.icmarc.org • Fax 202-682-6439 46987-0420-CRD20NOER | 8
SUMMARY DESCRIPTION
is publication provides a summary of the rules governing
the payment of funds from your Governmental 401 Plan,
457 Deferred Compensation Plan, or 403(b) Plan regarding
a Coronavirus Related Distribution. It is not a complete
description of the law. If there are any conicts between what
is written in this publication and what is contained in the law,
the applicable law will govern.