Federal Tax- Withhold 20 percent
Federal Tax- Do Not Withhold
Rollover the Partial Amount of
The remaining balance will be paid directly to you in a single sum payment, less federal tax withholding.
TEACHER AND EMPLOYEE RETENTION INCENTIVE (TERI)
PAYOUT ELECTION FORM
SC Public Employee Benefit Authority
South Carolina Retirement Systems
PO Box 11960, Columbia, SC 29211-1960
Print or type in blue or black ink
Pay the total Single Sum Payment amount directly to you (less required federal tax withholding). *May be subject to a tax penalty. Single Sum Payments are required to be directly deposited. See instructions.
Section I For your TERI balance payout, please select ONE of the payment methods below (see Page 2 of this form for detailed explanation).
Section II Tax Withholding Information (Applicable for any taxable portion paid directly to you.)
MEMBER'S OR ALTERNATE PAYEE'S SIGNATURE _______________________________________________ DATE ______________________________
WITNESS ___________________________________________________________ DATE _____________________________________________________
STATE OF ___________________________________________________ COUNTY OF _____________________________________________________
ACKNOWLEDGED BEFORE ME THIS DATE __________________________ NOTARY NAME _________________________________________________
MY COMMISSION EXPIRES ____________________________ NOTARY SIGNATURE ______________________________________________________
NOTARY BUSINESS PHONE _______________________________________________________________________________________________________
Account Number With Trustee/Plan (limit to 25 characters)
P.O. Box or Street Address
Name of Trustee (IRA Custodian/Employer Plan)
Section III COMPLETE THIS SECTION IF YOU SELECTED A DIRECT OR PARTIAL ROLLOVER ABOVE.
(Attach additional sheets listing partial rollover amount and rollover information if additional partial rollovers are requested.)
Section IV SIGNATURE AND NOTARY STATEMENT: FORM MUST BE NOTARIZED TO BE ACCEPTED
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.
Please contact PEBA's Customer Contact Center with any questions at 803.737.6800 or 888.260.9430, or www.peba.sc.gov.
You must attach a legible copy of your driver's license or special
identification card issued by your state Department of Motor Vehicles.
Account Types Available (Check only ONE box)
Consult trustee to determine plan type as necessary.
Be advised that this TERI account payment will have a TAX impact upon you. You should consult a tax advisor for questions concerning your payment options and tax liability. In accordance with S.C. Code Ann. ?9-1-2210, you must select one of the following methods for distributing your TERI funds. (Check only one box. If you select Partial Rollover, you must indicate an amount.) The portion of your contributions deemed to be non-taxable will be paid directly to you unless you choose to rollover the entire TERI balance.
Payee Last Name & Suffix (Jr., Sr., etc.)
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.
Choose ONE of the following:
for South Carolina state income tax.
Please see Instructions for Required Minimum
Distribution. Complete Information in Section III.
Please see Instructions for Required Minimum Distribution.
Complete Information in Section III. For direct deposit, see instructions.
in addition to the required 20 percent federal tax calculation.