CSS2HTML: WEB4275.XDP

Form 4275  Revised 6/23/2020

COVID-19 Certification

I hereby certify that the distribution that I have requested from the South Carolina Retirement Systems meets the requirements of Section 2202 of the Coronavirus Aid, Relief, and Economic Security Act

(CARES Act) of 2020 for a coronavirus-related distribution because one of the following applies: 

(a) I have been diagnosed with the virus SARS-CoV-2 or with coronavirus disease 2019 (COVID-19) by a test approved by the Centers for Disease Control and Prevention; 

(b) my spouse or dependent (as defined in section 152 of the Internal Revenue Code of 1986) has been diagnosed with such virus or disease by such a test; or 

(c) I have experienced adverse financial consequences as a result of me, my spouse, or someone who shares my primary residence: being quarantined, furloughed, laid off, or having work hours reduced due to such virus or disease; being unable to work due to lack of child care due to such virus or disease; closing or reducing the hours of a business owned or operated by me, my spouse, or someone who shares my primary residence due to such virus or disease; or having a reduction in pay (or self-employment income), a job offer rescinded, or a start date for a job delayed due to such virus or disease.

I further certify that, including this distribution, the aggregate amount of retirement plan distributions received by me and treated as coronavirus-related distributions for this tax year does not exceed $100,000.

I wish to have the following federal and South Carolina state tax withholding on my payment(s):

Federal income tax dollar amount:

$

South Carolina income tax dollar amount:

$

or percentage:

or percentage:

Signature:

Date:

Printed name:

Social security number: