STATE OF CALIFORNIA
PST RETIREMENT PLAN
BENEFIT PAYMENT APPLICATION
STD. 951 (REV. 12-97)
RETURN COMPLETED APPLICATION TO:
PST RETIREMENT PLAN
Department of Personnel Administration
1800 15th Street
Sacramento, CA 95814-6614
Payment Information
PRIVACY STATEMENT
: Providing the social security account number is voluntary in accordance with the Privacy Act of 1974 (PS 93-579). If,
however, the social security account number is not included, it may result in a delay or in our inability to comply with your request.
BIRTHDATESOCIAL SECURITY NUMBER
(See Privacy Statement)
RETIREMENT / SEPARATION DATENAME
(Last) (First) (M.I.)
TELEPHONE NUMBER
ADDRESS
(Number, Street, Apt. Number)
CITY STATE ZIP CODE
B. COMMENCEMENT DATE ELECTION--You may choose to receive your lump-sum payment as soon as possible (after the 90-
day waiting period) or at a future date you have elected. Payment cannot be deferred beyond age 70 1/2.
Month Year
INDICATE WHEN YOU WOULD LIKE PAYMENT ISSUED
C. CERTIFICATION--
YOU MUST OBTAIN RETIREMENT VERIFICATION FROM YOUR PERSONNEL OFFICE
or provide a copy of the
Notice of Personnel Action Report of Separation (NOPA) you will receive approximately three weeks after your last working day. Return
this Application and, if applicable, the NOPA to the Savings Plus Program office at the address listed at the top of this Application.
IMPORTANT:Your Application will NOT be processed for payment if you do not attach your NOPA, or if Section D has not been
signed by your Personnel Office. Additionally, you must also include a copy of your photo identification and
social security card.
ISSUE PAYMENT
I understand pursuant to Federal Regulations, the election of a commencement date is FINAL AND IRREVOCABLE and it is within the
authority of the State of California to approve or disapprove this request. I declare, under penalty of perjury, pursuant to the laws of the
State of California, that the foregoing is true and correct.
Signature
Date signed
I certify that this employee is retired/separated from State service effective:
D. RETIREMENT / SEPARATION VERIFICATION
(Obtain from YOUR Personnel Office--see notes in Section C above)
If more information is needed, please contact me at:
AUTHORIZED DEPARTMENT REPRESENTATIVE
(Please Print or Type)
DATE SIGNEDSIGNATURE
A. EMPLOYEE INFORMATION--Please note that you are not eligible to apply for a refund until 90 days after you retire or
separate from all State employment. If this application is received by our office before you become eligible for payment, it
will not be processed until the month following the 90-day period.
1. Payments are mailed to the address you have provided on this
Application. (See Section A above.) Payments will not be
made unless this Application and the NOPA are received by
the Savings Plus Program office at least 30 days before the
payment is scheduled for mailing date.
2. Payments are made in a lump sum. Income taxes will NOT be
withheld IF your account balance is less than $2,500. If your
account exceeds $2,500, taxes will be mandatorily withheld at
the rate of 15% for Federal and NONE for State. In January of
the following year, a W-2, Wage and Tax Statement, will be
mailed to the address you have provided on this Application.
ISSUE PAYMENT AS SOON AS POSSIBLE
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