Cd-0773-0313 Spouse Rollover Election Form For Distribution From The Pension Fund Page 2
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2CD-0773-0313
SPOUSE ROLLOVER ELECTION FORM
INSTRUCTIONS
I M P O R T A N T
1. If you have difficulty completing this form, please call the Division of Pensions and
Benefits, Office of Client Services at (609) 292-7524 for assistance.
PLEASE NOTE: The Division of Pensions and Benefits cannot give tax advice.
2. This form must be completed and submitted to the Division of Pensions and Benefits
before your payment can be processed. We strongly recommend that you read Fact
Sheet #27, The Taxability and Mandatory Withholding of Income Tax from your
Pension Distribution, before completing this form. Fact Sheet #27 contains important
tax information and explains the options that are available to you.
PART 1: Complete all of the items in Part 1. Please print YOUR name, address, Social Security number, and
daytime telephone number. See cover letter for the deceased member’s membership number (item 5).
PART 2: Select a payment option by completing Part 2. To elect a direct rollover, you must provide the name
of the IRA Sponsor (usually a financial institution) or employer plan that will accept your rollover. If you
are unsure how to invest your money, you can temporarily establish an IRA to receive your payment.
Selection 1 - If you choose this selection, the Division of Pensions and Benefits will make your ben-
efit check payable to you at the address listed in Part 1. 20% of the taxable portion of
your payment will be withheld as federal income tax.
Selection 2 - If you choose this selection, there will be a direct rollover of the entire taxable and
non-taxable portion of your payment. You must insert the name of the financial insti-
tution or employer plan that will accept your rollover. The Division of Pensions and
Benefits will mail a check to you representing the entire payment which will be made
payable to the institution or employer plan you selected to accept your rollover.
Selection 3 - If you choose this selection, there will be a direct rollover of part of your payment.
You must insert the dollar amount of the portion that you wish to roll over and the name
of the financial institution or employer plan that will accept your rollover. The remaining
portion of your payment will be paid to you in a separate check, less 20% for federal
tax, on the taxable amount of the remaining balance. If your total payment includes a
return of after-tax contributions, both the direct rollover and the payment to you will
include a portion of after-tax contributions.
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