Form Orp-3 - Optional Retirement Program Of The University Of North Carolina Acknowledgement Of Particpation Page 2

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contracts of an insurance company, or through the purchase of one or more investment funds of a plan approved mutual
fund company, with whom the individual participated in the plan, or which they could have participated in had
participation continued in the UNC Optional Retirement Program.
NORTH CAROLINA STATE INCOME TAX EXEMPTION
If you were enrolled in the University of North Carolina ORP on or before August 12, 1989, your UNC ORP retirement
benefits are exempt from North Carolina State income tax. If you withdraw, transfer or rollover ALL of your UNC ORP
contributions to an IRA or another employer’s retirement plan, you will forfeit your right to this exemption.
STATE HEALTH PLAN OF NORTH CAROLINA RETIREE GROUP HEALTH COVERAGE
Vested participants in the UNC ORP may be eligible to continue group health insurance coverage as a retiree under the
State Health Plan. To be eligible for group health insurance you must be receiving a monthly retirement benefit under the
UNC ORP. If you withdraw, transfer or roll over ALL of your UNC ORP contributions to an IRA or another employer’s
retirement plan, you will forfeit your right to the State’s retiree group health plan coverage.
Upon retirement, you may enroll in the State of North Carolina’s Retiree Group Health Plan with coverage to become
effective on the first day of the month following the commencement of your monthly UNC ORP benefit. You will be eligible
for coverage if you were first employed with the State of North Carolina prior to October 1, 2006 and had five or more
years of contributory retirement service. If you were hired on or after October 1, 2006, you must retire with 20 or more
years of retirement service credit to be eligible for a non-contributory health care benefit. If you have at least five years of
retirement service credit, but less than 20, you may be eligible for coverage by paying a higher percentage of the
premiums. In all cases, if coverage is elected for your dependents, you must pay the full cost of dependent coverage.
INSTRUCTIONS FOR COMPLETING FORM ORP-3
SECTION A (EMPLOYEE DATA) & SECTION B (RETIREMENT PLAN PARTICIPATION) - Please complete all information in
Section A and Section B.
SECTION C (REASON FOR TERMINATION) - Check the applicable box that corresponds to your reason for termination.
Follow the instructions for completing your form as follows:
Retirement - If you are retiring from the University and believe you may be eligible for State Health Plan of North Carolina
Retiree Group Health Coverage, select this box and sign and date the form at the end of Section C. You must return your
form to your UNC Campus Human Resources-Benefits Office.
Transfer to Another UNC Campus – If you are transferring to another UNC Campus, please select this box in Section C and
sign and date the form at the end of Section C. You must return your Form ORP-3 to your UNC Campus Human Resources-
Benefits Office of the campus where your employment has ended. Please keep in mind that when transferring from one
UNC Campus to another UNC Campus, your election to participate in the UNC-ORP is irrevocable, therefore you must
re-enroll in the ORP at your new employing UNC campus.
New Job Opportunity & Other – If you are leaving the University and have other employment or do not yet have another
job, please select this box and sign and date the form at the end of Section C. You must also select one of the options
under this section as it applies to your personal circumstance. Please read the description for each to determine which box
to check:
Not Continuing Participation in a “Like” Retirement Plan – If you select this box we will validate your retirement
plan participation to determine your vesting status. If you are vested, you will receive an acknowledgement of
your vested status from The University.

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