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Roth IRA

Section II  Tax Withholding Information  (Applicable for any taxable portion paid directly to you.)

MEMBER'S OR ALTERNATE PAYEE'S SIGNATURE                                                                                                                       
                             
WITNESS                                                                                                                                                                                 

STATE OF                                                                                                      COUNTY OF

ACKNOWLEDGED BEFORE ME THIS DATE                                       NOTARY NAME

MY COMMISSION EXPIRES                                                                 NOTARY SIGNATURE

NOTARY BUSINESS PHONE                                                                                                                                                               

I do hereby apply for a refund of the total amount of contributions plus interest credited to me in the above-checked retirement system. I understand that upon payment of such amount I do hereby waive for myself, my heirs, and assigns all my rights, title, and interest in any fund under the care and control

of this retirement system. I also understand that by receiving a refund that I am forfeiting my service credit and giving up all rights to any future service retirement or disability retirement benefits.  I further understand that my refund request will be canceled if I return to employment covered by the Retirement Systems prior to payment of my refund. This includes any employment for which I am eligible to join the SC Retirement System, the Police Officers Retirement System, or the State Optional Retirement Program.

 

Section I   For your refund payout, please select ONE of the payment methods below. (See Page 2 for detailed explanation.)  

REFUND REQUEST

SC Public Employee Benefit Authority

South Carolina Retirement Systems

Customer Service Refund Claims

P.O. Box 11960, Columbia, SC 29211-1960

Text Field

Mailing Address

City

Former/Maiden Name (if applicable)

CHECK ONE:

Pay the total Single Sum Payment  directly 

to you (less required federal tax withholding).

Payment must be directly deposited -- 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 (Limit to 25 characters)

Name of Trustee/Plan

P.O. Box or Street Address

City

State

Zip + 4

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.

Please read all information on Page 2 before signing this form IN BLUE INK. 

I hereby certify I have read and understand the information on this form, including the tax rules, and I agree to the terms stated.

(Certified copy of legal authorization required with signature other than applicant's)  

 (Please print)

Please call SC Retirement Systems' Customer Services department with any questions: 803-737-6800 or 800-868-9002 (within S.C. only)

 (Required only when signed by a mark) 

DATE

DATE

Social Security Number

Date of Birth

First/Middle Name

Last Name & Suffix

Telephone Number

ZIP+4

State

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 SOUTH CAROLINA RETIREMENT SYSTEMS.  THE SOUTH CAROLINA RETIREMENT SYSTEMS RESERVES THE RIGHT TO REVISE THE CONTENT OF THIS DOCUMENT. 

South Carolina Retirement System

Police Officers Retirement System

Check here if you are the alternate payee under a Qualified Domestic Relations Order (Member SSN                                                     )

Single-Sum Payment

Partial Rollover

PRINT OR TYPE IN INK

Judges and Solicitors Retirement System

General Assembly Retirement System

Direct Rollover

Rollover Pre-Tax Funds Only 

Rollover Total Balance 

Rollover the Partial Amount of

403(a) Annuity Plan

401(a) Defined Benefit Qualified Plan

401(a) or 401(k) Defined Contribution Qualified Plan

Federal Tax- Do Not Withhold

Federal Tax- Withhold 20 percent

Account Types Available (Check only ONE Box)

Consult trustee to determine plan type as necessary.

 403(b) Annuity Plan

The remaining balance will be paid directly to you in a single sum payment, less federal tax withholding.  For direct deposit, see Page 2.

Traditional IRA

$   

Please withhold

$   

Please withhold

in addition to the required 20 percent federal tax calculation.

for South Carolina state income tax.

$   

Section IV  Signature and Notary Statement --  Form must be notarized to be accepted. 

%   

or

Other-see instructions on Page 2 

Specify Plan Name

Form 4101

Revised 7/9/2012

Page 1