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
Form 7800
Revised 2/28/2025
Page 1
Complete in blue or black ink.
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)
P.O. Box or Street Address
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.
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.
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:
(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.
for South Carolina state income tax.
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)
(Required only when signed by a mark)
MEMBER'S OR ALTERNATE PAYEE'S SIGNATURE
ACKNOWLEDGED BEFORE ME THIS DATE