Form Fs-0486-1014 Supplemental Annuity Collective Trust Withdrawal Application
ADVERTISEMENT
1STATE OF NEW JERSEY
PO BOX 295
APPLICATION FOR
DEPARTMENT OF THE TREASURY — DIVISION OF PENSIONS & BENEFITS
TRENTON, NJ 08625-0295
WITHDRAWAL
SUPPLEMENTAL ANNUITY COLLECTIVE TRUST
(Please print or type.)
1. Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 5. Social Security #______ - ______ - ________
(LAST)
(FIRST)
(MIDDLE)
2. Address _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 6. Date of Birth _______ / _______ / _______
(MONTH)
(DAY)
(YEAR)
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 7. Gender
Male
Female
3. Retirement System _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 8. Home Phone # (_____) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
4. Membership # _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 9. Business Phone # (_____) _ _ _ _ _ _ _ _ _ _ _ _ _ _
10.
I am terminating my membership in the above Retirement System and therefore request withdrawal of the value of
my account(s) in accordance with the provisions of Chapter 123, P.L. 1963 and the rules and regulations promulgated
thereunder.
11.
The taxable portion of your payment may be paid directly to you less 20% of the taxable amount withheld for federal
income tax or it may be rolled over to an IRA or other employer’s defined contribution plan. Please indicate your
choice by checking one of the boxes below and following the instructions for the completion of the remainder of the
form. If Item 11 is not complete or is completed incorrectly, the Division of Pensions and Benefits will automatically
withhold 20% federal income tax.
Withhold 20% federal income tax on the taxable portion of my payment.
For the options below, refer to the “Change in Tax Treatment Resulting from a Direct Rollover” portion of Fact
Sheet #27, The Taxability and Manatory Withholding of Income Tax from your Pension Distribution.
Roll over the entire amount of my account
IRA (G)
to _________________________________________________________________
Employer Plan (H)
(PRINT THE NAME OF THE FINANCIAL INSTITUTION OR OTHER EMPLOYER PLAN)
Roll over __________________________ %
IRA (G)
to _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Employer Plan (H)
(PRINT THE THE NAME OF FINANCIAL INSTITUTION OR OTHER EMPLOYER PLAN)
This option is only available if the taxable portion of your payment is $500 or more.
12. SIGNATURE OF APPLICANT _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
(SIGNATURE )
FOR DIVISION USE ONLY
WRD ______________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
FS-0486-1014
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