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 information in Section III
DEFERRED ANNUITY ACCOUNT (JSRS)
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).
Section I Select ONE of the payment methods below (See reverse side (page 2) of this form for detailed explanation.)
Complete Information in Section III
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 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 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.
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:
Please withhold $______________________________ in addition to the required 20% Federal tax calculation.
Please withhold $______________________________ for South Carolina State income tax.