Refund Request - Form 4101 South Carolina Retirement Systems
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1
2Form 4101
REFUND REQUEST
CHECK ONE:
Revised 12/06/2006
South Carolina Retirement System
State Budget and Control Board
Page 1
South Carolina Retirement Systems
Police Officers Retirement System
Customer Service Refund Claims
General Assembly Retirement System
Box 11960, Columbia, SC 29211-1960
Judges and Solicitors Retirement System
PRINT OR TYPE IN INK
Section I
MEMBER / ALTERNATE PAYEE INFORMATION
Last Name & Suffix
First/Middle Name
Date of Birth
Social Security Number
Former/Maiden Name (if applicable)
Mailing Address
City
State
ZIP+4
Telephone Number
Check here if you are the alternate payee under a Qualified Domestic Relations Order (Member SSN
)
I do hereby apply for a refund of the total amount of contributions plus interest credited to me in the above-checked Retirement System. I understand that
upon payment of such amount I do hereby waive for myself, my heirs, and assigns all my rights, title, and interest in any fund under the care and control
of this Retirement System. I also understand that by receiving a refund that I am forfeiting my service credit and giving up all rights to any future
service retirement or disability retirement benefits. I further understand that my refund request will be canceled if I return to employment
covered by the Retirement Systems prior to payment of my refund. This includes any employment for which I am eligible to join the SC
Retirement System, the Police Officers Retirement System, or the State Optional Retirement Program.
NOTE: Refunds for members of the SC Retirement System and Police Officers Retirement System are payable within 6 months after demand, but not less
than 90 days after termination of employment. All required paperwork must be received from the member and the employer before a refund can be paid.
I terminated from
on
Employer
Date
Section II For your refund payout, please select ONE of the payment methods below. (See page 2 for detailed explanation.)
Lump-Sum Payment
Direct Rollover
Partial Rollover
Pay the total refund amount (less required
Rollover the taxable portion of my refund to the
Rollover the Partial Amount of
trustee/plan named below.
$
to the trustee/plan named
federal tax withholding) directly to me.
The portion you rollover will not be taxed until you
below. Pay the remaining balance directly to me
take it out of the eligible plan.
in a lump-sum payment.
(Information must be provided in Section III)
(Information must be provided in Section III)
Section III
COMPLETE THIS SECTION IF YOU SELECTED A DIRECT OR PARTIAL ROLLOVER ABOVE.
Account Number With Trustee/Plan (Limit to 25 characters)
Account Types Available
(Check only ONE box)
I R A
Annuity Plan - 403(b)
Name of Trustee/Plan
Qualified Plan - 401(k) or 401(a)
Other-see instructions on page 2
P.O. Box or Street Address
Specify Plan Name
City
State
Zip + 4
You must attach a legible copy of your current driver's license or special
identification card issued by your State Department of Transportation or Public Safety.
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.
Date:
MEMBER'S OR ALTERNATE PAYEE'S SIGNATURE
(Certified copy of legal authorization required with signature other than applicant's)
Date:
WITNESS
(Required only when signed by a mark)
STATE OF
COUNTY OF
ACKNOWLEDGED BEFORE ME THIS DATE
NOTARY NAME
(Please print)
MY COMMISSION EXPIRES
NOTARY SIGNATURE
NOTARY BUSINESS PHONE
Please call SC Retirement Systems Customer Service with any questions: (800) 868-9002 (in state) or (803) 737-6800
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.
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