Fs-0423-0114 Distribution Form

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FS-0423-0114
STATE OF NEW JERSEY
DEPARTMENT OF THE TREASURY – DIVISION OF PENSIONS AND BENEFITS
SUPPLEMENTAL ANNUITY COLLECTIVE TRUST OF NEW JERSEY
PO Box 295, Trenton, New Jersey 08625-0295
DISTRIBUTION FORM
COMPLETE THIS FORM ONLY IF YOU HAVE SELECTED AN OPTION #2, LUMP SUM SETTLEMENT: This form is not
required if you selected Annuity Options 1,3,4,5, or 6.
Name:
________________________________________
Soc. Sec.#: _______________________________
Address: ________________________________________
Date of Birth: ____________________
Sex: M / F
________________________________________
Telephone ________________________________
________________________________________
Ret. System & #: _____________________________
Retirement Date: _________________________________
PART 1 – Designate your payment choice for each of your SACT types. Make (1) selection for each of your
SACT accounts.
A. SACT REGULAR
________ DIRECTLY TRANSFER _____% or $___________ ($500 minimum) of the amount qualified for
rollover with any remaining balance paid to me. Please complete PART 2 of this form.
or
________ PAY DIRECTLY TO ME the amount qualified for rollover. I understand 20% federal tax will be
withheld. (The check stub will provide detailed information for income tax reporting. This amount will be
included in the check representing your contributions.)
B. SACT TAX SHELTER
________ DIRECTLY TRANSFER _____% or $_________ ($500 minimum) of the amount qualified for
rollover. Please complete PART 2 of this form.
or
________ PAY DIRECTLY TO ME the amount qualified for rollover. I understand 20% federal tax will be
withheld. (The check stub will provide detailed information for income tax reporting.)
C. SACT QVEC – Direct Transfers not permitted.
________ Withhold federal tax per IRS schedule. or
________ Do not withhold tax.
PART 2 – Complete this section only if you have selected a direct transfer option above.
DIRECT MY TRANSFER TO MY ESTABLISHED: (Check one)
IRA ________
TRADITIONAL: ________
ROTH: ________
EMPLOYER PLAN: 401K________
401a________
403b________
457b________
Name of Plan______________________________________________
Mailing Address_________________________________________________________________________
PART 3 – I hereby authorize the New Jersey Division of Pensions and Benefits, Supplemental Annuity Collective
Trust to distribute my funds as directed above.
___________________________
____________________________________________________
Date
Signature

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