CSS2HTML: WEB7800.XDP

Check appropriate box: 

Termination or Age 60 Date:

Rollover the Partial Amount of                                         . The remaining balance will be paid directly to you in a single sum payment, less federal tax withholding. 

Complete Sections II, III, and IV.

DEFERRED ANNUITY ACCOUNT PAYOUT ELECTION FORM

SC Public Employee Benefit Authority

Judges and Solicitors Retirement System (JSRS)
202 Arbor Lake Drive, Columbia, SC 29223

City

Telephone Number

Form 7800
Revised 2/28/2025
Page 1
Complete in blue or black ink.

System:  JSRS

Pay the total Single Sum Payment amount directly to you (less required federal tax withholding). 

For direct deposit, see Page 2. 

SECTION I   SELECT ONE OF THE PAYMENT METHODS BELOW (See Page 2 of this form for detailed explanation.)           

Complete Sections III and IV.

SECTION II   TAX WITHHOLDING INFORMATION (Applicable for any taxable portion paid directly to you.)

Account Number With Trustee/Plan (limit to 25 characters)

Zip + 4

State

City

P.O. Box or Street Address

Name of Trustee/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 OR BLACK INK. 

I hereby certify I have read and understand the information on this form, including the information on the reverse side and in the attached rollover

notice, and I agree to the terms stated.

Please call PEBA's Customer Service with any questions: 803.737.6800 or 888.260.9430.

You must attach a legible copy of your driver's license or special identification card issued by your state Department of Transportation or Public Safety.

Account Types Available (Check only ONE Box)

Consult trustee to determine plan type as necessary.

First Name/Middle Name

State

This account payment will have a tax impact on 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 deferred 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 roll over the entire balance.

Social Security Number

Payee Last Name & Suffix (Jr., Sr., etc.)

Address

ZIP+4

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:

Email

Direct Rollover

(MEMBER SSN____________________)

Complete Sections II and IV.

Federal income tax: PEBA automatically withholds the mandatory 20% federal tax. To withhold additional federal taxes, go to www.irs.gov/fw4r to download, print and sign Form W-4R. Return the completed Form W-4R to PEBA with this form.

Please withhold

for South Carolina state income tax.

or

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

(Certified copy of legal authorization required with signature other than applicant's)  

 (Please print)

 (Required only when signed by a mark) 

DATE

DATE

MM/DD/YYYY

MEMBER'S OR ALTERNATE PAYEE'S SIGNATURE

WITNESS

STATE OF

COUNTY OF

ACKNOWLEDGED BEFORE ME THIS DATE

NOTARY NAME 

MY COMMISSION EXPIRES 

NOTARY SIGNATURE

NOTARY BUSINESS PHONE