Section II Tax Withholding Information (Applicable for any taxable portion paid directly to you.)
MEMBER'S OR ALTERNATE PAYEE'S SIGNATURE
STATE OF COUNTY OF
ACKNOWLEDGED BEFORE ME THIS DATE NOTARY NAME
MY COMMISSION EXPIRES NOTARY SIGNATURE
NOTARY BUSINESS PHONE
Section I For your refund payout, please select ONE of the payment methods below. (See Page 2 for detailed explanation.)
SC Public Employee Benefit Authority
Customer Service Refund Claims
202 Arbor Lake Drive
Columbia, SC 29223
Former/Maiden Name (if applicable)
Pay the total Single Sum Payment directly
to you (less required federal tax withholding).
For direct deposit see Page 2.
Choose ONE of the following:
Section III Complete this section if you selected a direct or partial rollover above.
Account Number With Trustee/Plan (Limited to 25 characters)
P.O. Box or Street Address
You must attach a legible copy of your current driver's license or special
identification card issued by your state Department of Transportation or Public Safety.
By executing this form I am requesting a refund of my account balance in the retirement system selected above. I understand that by receiving this refund, I am cancelling my membership in the selected retirement system; forfeiting all of my service credit in that system; and waiving any right or interest I have in that system, including giving up all rights to any future service or disability retirement benefits in that system.
I certify that I have read and understand the information provided on this form, including the information on the reverse side and in the attached rollover notice, and I agree to the terms stated.
(Certified copy of legal authorization required with signature other than applicant's)
Please call PEBA's Customer Service with any questions: 803.737.6800 or 888.260.9430.
(Required only when signed by a mark)
THE LANGUAGE USED IN THIS DOCUMENT DOES NOT CREATE ANY CONTRACTUAL RIGHTS OR ENTITLEMENTS AND DOES NOT CREATE A CONTRACT BETWEEN THE MEMBER AND THE PUBLIC EMPLOYEE BENEFIT AUTHORITY. THE SOUTH CAROLINA PUBLIC EMPLOYEE BENEFIT AUTHORITY RESERVES THE RIGHT TO REVISE THE CONTENT OF THIS DOCUMENT.
Please complete form
in blue or black ink.
Rollover the Partial Amount of
Account Types Available (Check only ONE Box)
Consult trustee to determine plan type as necessary.
The remaining balance will be paid directly to you in a single sum payment, less federal tax withholding. For direct deposit, see Page 2.
The default federal tax withholding is 20%. Please go to www.irs.gov/fw4r and send PEBA a completed W-4R if you would like additional federal tax withholding.
for South Carolina state income tax.
Section IV Signature and Notary Statement -- Form must be notarized to be accepted.