Employee Tax Withholding Certificate

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295
PO BOX
FS-0957-0814
,
08625-0295
TRENTON
NJ
State of New Jersey
Department of the Treasury — Division of Pensions and Benefits
Supplemental Annuity Collective Trust
EMPLOYEE TAX WITHHOLDING CERTIFICATE
PLEASE COMPLETE THIS FORM IF YOU SELECT A LUMP SUM SETTLEMENT
(Please print or type.)
1. Name: ________________________________________________________________________________
(Last)
(First)
(Middle)
2. Address: ______________________________________________________________________________
(Street)
(City)
(State)
(Zip Code)
3. Retirement System: _________________________ 4. Membership No.: __________________________
5. Effective Date of Retirement/Withdrawal: _________ 6. Social Security No.: ________________________
❏
❏
7. Date of Birth: ______________________________ 8. Sex:
Male
Female
Month
/
Day
/
Year
(
)
9. Home Phone#: _____________________________ 10. Business Phone#: ________________________
(
)
(Area Code)
(Area Code)
11. FEDERAL INCOME TAX WITHHOLDING: (Check one)
❏
❏
Withhold tax from my check
Do not withhold tax from my check
S
(D
)
IGNATURE
ATE
PREPAYMENT OF TAX — You are responsible for Federal Income Tax that may be due on your account distri-
bution and are subject to tax penalties if your payment of estimated tax withholding is inadequate.
INCOME TAX INFORMATION — Consult you tax advisor or the IRS for detailed tax information.
(a) The table income portion of your distribution may be rolled over to an IRA or another qualified
tax-sheltered plan within 60 days of the check date.
(b) The taxable amount of your distribution may be eligible for special averaging. See IRS Form #4972
“ Tax on Lump-Sum Distributions. ”
(c) If you are under the age of 55, the taxable portion of your distribution may be subject to an early
withdrawal penalty if not rolled over within 60 days of the check date. See IRS Publication #575
“Pension and Annuity Income.”
NOTE: If you do not return this form within 30 days, the required Federal Income Tax will be withheld and the
check forwarded.
TAX WITHHOLDING CERTIFICATE — CONFIRMATION OF RECEIPT
SACT TYPE
ADMINISTRATOR’S SIGNATURE
DATE

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