Form 4251
Revised 1/5/2024
Page 1 of 2

OFFICE USE ONLY
System:

NOTICE OF WITHHOLDING - NON-SPOUSE REFUND
SC Public Employee Benefit Authority

Customer Death Claims Unit

202 Arbor Lake Drive, Columbia, SC 29223

Beneficiary's SSN:

Name of Deceased Member/Retiree:

Decedent's Social Security Number:

SECTION 1    PAYOUT OF DECEDENT'S RETIREMENT CONTRIBUTIONS AND INTEREST (See page 2 of this form for detailed explanation.)

SECTION 4    SIGNATURE

PAYEE SIGNATURE

DATE:

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. 

Account Type Available

Name of Beneficiary:

* You must attach to this form a written certification from the IRA provider that states they will treat the IRA as an Inherited IRA.

Please contact PEBA's Customer Service with any questions at 803.737.6800 or 888.260.9430, or www.peba.sc.gov.

I hereby certify I have read and understand the attached instructions and rollover notice, including all tax information, and I agree to the terms stated. This form is effective for 180 days from the date signed. I certify that all statements and information provided on this form are complete and accurate to the best of my knowledge and belief.

A rollover (indicate desired amount) 

to the individual retirement account (IRA)/plan named below. Pay the remaining balance, with the required federal tax withheld, in a direct lump-sum payment.

SECTION 3   ROLLOVER ACCOUNT INFORMATION (applicable only if you selected a direct or partial rollover)

Please select ONE of the payment methods below:

Contributions and interest total 

Of this amount

are taxable funds.

A direct payout of all of the deceased member's funds, with the required 20% federal tax withheld.

Lump-Sum Payment

Please complete Sections 3 and 4.

Direct Rollover

Partial Rollover

SECTION 2   ADDITIONAL TAX WITHHOLDING (applicable for any taxable portion paid directly to you)

Please complete Sections 2, 3 and 4.

Please complete Sections 2 and 4.

or               % for South Carolina state income tax.

Please withhold $

Choose ONE of the following: 

IRA/Plan Account Number (limit to 25 characters)

Name of IRA Custodian/Plan Trustee

P.O. Box or Street Address

Zip + 4

State

City

South Carolina state income tax: If you do not complete this section, no state taxes will be withheld.