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Form 4275  Revised 4/2/2020

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 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 being quarantined, being furloughed or 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, or closing or reducing hours of a business owned or operated by me 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: