Withdrawal_of_Contributions_App

Withdrawal_of_Contributions_App - ARIZONA STATE RETIREMENT...

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Forfeitures Application for Withdrawal of Contributions & Termination of Membership Page 1 of 2 Revised: 10/26/09 ARIZONA STATE RETIREMENT SYSTEM (ASRS) A PPLICATION FOR W ITHDRAWAL OF C ONTRIBUTIONS AND T ERMINATION OF M EMBERSHIP PLEASE PRINT COMPLETE & SEND TO: ASRS PO Box 33910 Phoenix, AZ 85067-3910 Phoenix (602) 240-2000 Tucson (520) 239-3100 Toll-free (800) 621-3778 TTY (602) 240-5333 FAX (602) 240-2096 www.azasrs.gov Disclosure of your Social Security number is mandated by Section 6109 of the Internal Revenue Code. The ASRS will use Social Security numbers only to obtain information about an individual’s ASRS account and to inform the Internal Revenue Service of distributions and withholdings with respect to the individual’s account. SECTION 1 - Member Information (Complete all requested information.) Social Security Number Member Name (Last) (First) (Middle Initial) Mailing Address Daytime Telephone Number ( ) City State ZIP Date of Birth (MM/DD/YYYY) Date of Termination (MM/DD/YYYY) Last ASRS Employer SECTION 2 - Distribution Election Read and check one of the three following distribution elections. Complete the information as applicable. 100% of Payment to Member * Your entire withdrawal will be paid directly to you. (Please complete Section 3 if you would like your check deposited directly into your bank account.) OR 100% Direct Rollover to Eligible Retirement Plan ** Your entire withdrawal will be paid to the eligible retirement plan as specified in the Receiving Eligible Retirement Plan Information section below. OR Combination: Partial Rollover * ** Part of your withdrawal will be paid as a rollover to the eligible retirement plan as specified in the Receiving Eligible Retirement Plan Information section below. The remaining amount of your withdrawal will be paid to you. Total Amount of rollover $ Check here if you want your nontaxable money (i.e., any after-tax money such as service purchase or pre- 1986 deposits) rolled over to the account listed below. The remaining amount of your withdrawal will be paid to you. Receiving Eligible Retirement Plan Information: (Complete this section only If rolling over all or a portion of your withdrawal.) Type of account (check one): 403(b) 403(a) 401(k) 457(b) (governmental) 401(a) (defined contribution plan) 401(a) (defined benefit plan) Traditional IRA Account Number: Name of Receiving Institution: Address: City, State, ZIP * For any payment made to you (not rolled over to an eligible plan), tax laws require the ASRS to withhold 20% of the taxable amount for federal withholding and 5% of the entire amount for state tax withholding. If you are not age 55 or older in the calendar year you terminate employment and you take your forfeiture prior to age 59 1/2, any taxable distribution paid directly to you may be subject to an additional 10% early withdrawal tax. ** Nontaxable contributions may only be rolled over to defined contribution plans described under the Internal Revenue Code (IRC)
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This note was uploaded on 11/21/2011 for the course KAPLAN UNI MT 140 taught by Professor Thum during the Spring '10 term at Kaplan University.

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Withdrawal_of_Contributions_App - ARIZONA STATE RETIREMENT...

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