Application For Refund Of Contributions Form - Employees' Retirement System Of Georgia
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APPLICATION FOR REFUND OF CONTRIBUTIONS - GDCP
1. Please print or type clearly.
2. Send this form to your Payroll Department. Do not send to Georgia Defi ned Contribution Plan (GDCP).
3. If the taxable portion (interest earned) of your refund is less than $200.00, GDCP will withhold federal income tax. Typically the rate is
less than $200.00, GDCP will withhold federal income tax. Typically the rate is
less
30%, or if you are over 59 1/2 , the withholding rate is 20%.
4. If the taxable portion (interest earned) of your refund is more than $200.00, GDCP is required to withhold federal income tax unless
you directly roll over the taxable portion to another eligible retirement plan. You will be notifi ed by GDCP if this applies to you.
5. Refunds include accumulated employee contributions and credited interest earnings (if any).
6. Upon receipt of refund application in this offi ce, please allow 8 weeks for processing.
SECTION 1 - MEMBER INFORMATION
___________________________________________________
___________________________________________________
__________________________________________________
Name:
SSN:
(Last)
(First)
(MI)
(Maiden)
Mailing Address: _____________________________________________________________________________________________
(Street)
(City)
(State)
(Zip Code)
____/____/____
____/____/____
____/____/____
Date of Birth:
E-mail : ___________________________
E-mail : ___________________________
Daytime Phone No: (_______) __________________
(mm)
(dd)
(yyyy)
State Agency/Department/School System/Unit of the Board of Regents in which you were employed: __________________________
___________________________________________________________________________________________________________
SECTION 2 - MEMBER SIGNATURE
I understand that by receiving this refund I waive all rights to benefi ts accrued from this system.
Member Signature: ____________________________________________
Date:__________________________
SECTION 3 - PERSONNEL/PAYROLL USE ONLY
Please provide the following dates for the above mentioned employee (if applicable).
Termination Date:______/_____/_______
______/_____/_______
______/_____/_______
Last Payroll Deduction:
Last Payroll Deduction:
______/_____/_______
(mm)
(dd)
(yyyy)
(mm)
(dd)
(yyyy)
Salary: $______________________
Contributions: $______________ for ______/_______
ns: $______________ for ______/_______
ns: $______________
(mm)
(yyyy)
I certify that this employee has terminated employment, and that the total salary and contributions listed above are for the
month of termination.
Payroll Offi cer Signature: _________________________________________________ Date: ______/_____/_______
(mm)
(dd)
(yyyy)
Agency #: _______________________________________
Telephone #: (________) - __________________________
Email Address: _____________________________________
D3-DCP 03/2006
Two Northside 75 Suite 300 • Atlanta, GA 30318 • PHONE (404) 350-6300 (800) 805-4609 • FAX (404) 350-6308 •
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