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 SIGNATURENOTARY 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.)
SC Public Employee Benefit Authority
South Carolina Retirement Systems
Customer Service Refund Claims
P.O. Box 11960, Columbia, SC 29211-1960
Former/Maiden Name (if applicable)
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
Zip + 4
You must attach a legible copy of your current driver's license or specialidentification 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 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)
Social Security Number
Date of Birth
Last Name & Suffix
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 )
PRINT OR TYPE IN INK
Judges and Solicitors Retirement System
General Assembly Retirement System
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.
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.
Other-see instructions on Page 2
Specify Plan Name
Scripting must be enabled for this form to work correctly