Form Rsa 7 - Notice Of Final Deposit And Request For Refund - Alabama Page 2
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1
2P
III E
C
ART
MPLOYER
ERTIFICATION
If this is a state agency reporting unit, do not submit this form to the Retirement Systems until all warrant cancellations for
this individual have been processed by the state comptroller.
Name of Employing Agency:
Last retirement contribution was included in the
report.
(Month or if state employee, last payroll check issue date)
Last day for which employee is paid:
___
Month
Day
Year
I hereby certify the final salary payment has been made to the above named member and that this person has no further contract,
written or oral, to return to employment at said agency.
Signature of Payroll Official
Date
Note: Send this form with the payroll report which includes the member’s final deposit.
I
R
R
NSTRUCTIONS FOR
EFUND
EQUEST
Type or print in black ink.
Complete Part I and Part II and have your signature notarized. If you elect a direct rollover, the trustee must complete
the trustee information in Part II. The trustee official must verify if their plan accepts or does not accept non-taxable
funds. The trustee official must also sign to affirm acceptance of the transfer.
Part III should be completed by the employing agency. The refund will not be mailed until the Retirement Systems of
Alabama (RSA) receives the member’s final deposit and this form.
Any person who makes a false statement or falsifies a record in an attempt to defraud the RSA shall be guilty of a
misdemeanor, and upon conviction, be punished by a fine up to $500.00 and/or imprisonment not to exceed one year.
After this form has been completed, any address change must be submitted to RSA in writing and be signed by the
applicant. Include your Social Security number on any correspondence.
Employment Termination Statement
I hereby certify that I have permanently terminated my employment in any agency covered by the Retirement Systems
indicated and request that the contributions and applicable interest be distributed as shown. I further certify I do not have
a contract nor am I negotiating for employment with any agency covered by the System indicated. I understand that I am
not entitled to the total interest credited to my account, but a proportion of the total interest determined by the number of
years I have contributed. The refundable funds in my account are due to me and unpaid, and I understand that payment
in accordance with this form will release the RSA from any claim for other benefits.
No portion of the refund is subject to state of Alabama income tax.
If you have any questions regarding the taxability of your refund, contact the IRS or a tax advisor.
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