W-4P Withholding Certificate for 2012 - PSPRS

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W-4P Withholding Certificate for 2012 - PSPRS Powered By Docstoc
					                                  MEMBERSHIP ON/AFTER 1/1/2012
                       CORRECTIONS OFFICER RETIREMENT PLAN (Version: 8/1/2012)
                                    REVERSE DROP - Input Sheet
When inputting information, input dates in the mm/dd/yy format. Other than the dates, input all numbers with no
breaks or special characters (i.e., dashes or parentheses), the computer will format as necessary. Only input in
the white spaces.
TODAY'S DATE:                                            Reverse DROP Period (months)

Reverse DROP Date:
                                                           can't be determined yet
Participation Date:
PERSONAL INFORMATION
First Name
Middle Name
Last Name
Social Security No.
Sex                           Male             Female

Member Date of Birth
Marital Status                    Single       Married

SPOUSE INFORMATION
First Name                                                 Date of Birth
Middle Name                                                Social Security No.
Last Name                                                  Date of Marriage

ADDRESS AND PHONE OF MEMBER
                      Address 1                                                Address 2

          City                         State                         Zip

 Home Phone Number          Work Phone Number              Cell Phone Number

                  Email

DEPENDENT CHILDREN                                                                         No Dependents
Child #1 Name
Date of Birth
Disabled?
Child #2 Name
Date of Birth
Disabled?
Child #3 Name
Date of Birth
Disabled?
Child #4 Name
Date of Birth
Disabled?
Child #5 Name
Date of Birth
Disabled?
RETIREE EMPLOYMENT INFORMATION
Prior Service
        From                            Through              Employer                                               NONE
Flat number (years) >>




Leaves Without Pay
During my period(s) of covered service, I have been on leave of absence without pay for the number of entire pay periods
as indicated below:                                                                                            NONE
  Missed Pay Periods          Employer




Industrial Leave
During my period(s) of covered service, I have received compensation benefits under the Worker's Compensation Laws
of the State of Arizona as indicated below:
                                                                                                         NONE
           From                         Through              Employer




 Current Empoyer
Current Employer
  Service      From:                                             Completes 25 Yrs:
                 To:                                         <<<This is the Participation date.
Local Board Name
Compensation
List total compensation for the highest three consecutive years with the last twenty
completed years of credited service.
           Year                         Through                        Amount                                 Final Contribution to PSPRS
                                                                                                                  Amount
                                                                                                        Pay Period Ending
                                                                                                  Prior/Combined Salary
                                                                                                  per joinder agreement:
                                                                                                 Salary from other CORP
                                                                                                               employer:




PAYMENT INFORMATION
Payable to
Payment Method

DIRECT DEPOSIT INFORMATION
Financial Institution
Phone Number

MEMBER'S ACCOUNT INFORMATION
Bank ABA Routing #                                                       C12N RDROP         C11N RDROP         N-MOU      W-4 P    A-4 P
                                                              Print:
Account Type
                                                                          C4N RDROP                             Form 8        Form U3
Bank Account No.
                                                                       Print Forms: C12NRDROP, C11NRDROP, C4NRDROP (1&2), C8RDROP, C16, N-MOU, W-4P, A-4P, U3
Print Forms: C12NRDROP, C11NRDROP, C4NRDROP (1&2), C8RDROP, C16, N-MOU, W-4P, A-4P, U3
BENEFICIARY INFORMATION
Beneficiary Type          Primary                  Relationship       Spouse     Child          Parent

Beneficiary Name                                                      Fiancé     Friend         Other
SSN
Date(s) of Birth
                   Address 1                              Address 2

          City                      State          Zip            Phone Number            Same Info As Member


Beneficiary Type          Primary      Secondary   Relationship       Spouse     Child          Parent

Beneficiary Name                                                      Fiancé     Friend         Other
SSN
Date(s) of Birth
                   Address 1                              Address 2

          City                      State          Zip            Phone Number            Same Info As Member


Beneficiary Type          Primary      Secondary   Relationship       Spouse     Child          Parent

Beneficiary Name                                                      Fiancé     Friend         Other
SSN
Date(s) of Birth
                   Address 1                              Address 2

          City                      State          Zip            Phone Number            Same Info As Member


LOCAL BOARD INFORMATION

 FORMS PREPARED BY:
     PHONE NUMBER:
BOARD MEETING DATE:
Forms Date
  08/2012




       FOR CORP USE ONLY
  System               ID Number
NOTE: You may go to any of
the forms and type in
information that would
otherwise need to be
handwritten in. For example,
on Form P4, it asks when the
member's employment will
terminate. Before printing the
forms off, you may type the
information directly in the cell
designated by the red arrows
on any of the forms.
         Other Forms
                                  CORRECTIONS OFFICER RETIREMENT PLAN                         FORM C12N RDROP
                             3010 E. Camelback Rd. Suite 200, Phoenix, Arizona 85016                      08/12
                           PHONE: (602)255-5575 FAX: (602)296-2369 www.psprs.com
                          NOTIFICATION OF REVERSE DROP BENEFITS AND ELECTION
                                       FOR MEMBERSHIP ON/AFTER 1/1/2012


         PAYABLE TO:
                                              (Name of Member)

              DATE FIRST REVERSE DROP BENEFIT CREDITED:
              DATE LAST REVERSE DROP BENEFIT CREDITED:
                                DATE FIRST PAYMENT DUE:

TYPE OF BENEFIT: REVERSE Deferred Retirement Option Plan

BENEFITS UNDER ARIZONA CORRECTIONS OFFICER RETIREMENT PLAN:

Monthly benefit credited to the REVERSE DROP account or monthly pension payable to
member:


  The Local Retirement Board has met on                      and determined that the applicant above is
  eligible for the REVERSE DROP and the REVERSE DROP credit as shown above:



                     Name of Board                                    Signature of Board Chairman or Secretary


                                   ELECTION AND ACCEPTANCE BY MEMBER
 (Initial)
             I ELECT TO ACCEPT the REVERSE Deferred Retirement Option Plan credit as determined under above,
              representing the REVERSE DROP benefits payable to me under the Corrections Officer Retirement Plan.

I UNDERSTAND that this election to receive REVERSE DROP credits pursuant to this document and under the CORP
may not be revoked and is binding upon me or any beneficiary or survivor unless otherwise provided by law.



    DATE:
                                         Signature of Member                             Signature of Witness
                                    CORRECTIONS OFFICER RETIREMENT PLAN                                FORM C11N RDROP
                                3010 E. Camelback Rd. Suite 200, Phoenix, Arizona 85016                            08/12
                                  (602) 255-5575 FAX (602) 255-5572 www.psprs.com
                                    BENEFIT CALCULATIONS (REVERSE DROP)
                                                  A.R.S. Section 38-885.01
                                        FOR MEMBERSHIP ON/AFTER 1/1/2012
     Member's Name:                                                                     Birth Date:
         Employer:                                                                          S.S.N.:
               Current Employer - YEARS OF SERVICE:
                      plus PRIOR YEARS OF SERVICE:
                           less LEAVES WITHOUT PAY:
                         less REVERSE DROP PERIOD:                                Reverse DROP Date:
                     LENGTH OF CREDITED SERVICE:
                 Amount of Final contribution to CORP:                       for Pay Period Ending
A. COMPENSATION: BASE SALARY paid to member during a period of 60 consecutive months of credited service in
which member received highest base salary within the last 120 months of service:



                                                                                                                                    OVER-WRITES
                                                                                                                           (Manual will over-write Conditional)
                                                                                                                                   Manual        Conditional

B. TOTAL AMOUNT of highest 60 consecutive months of base salary:                                                            B
C. AVERAGE MONTHLY COMPENSATION (Line B / 0 months):                                                                        C
D. For retirement with 25 or more years of credited service:
          1. Line C x 62.5%:                                                                                               D1
          2. PLUS 2.5% of Line C for each year of credited service
             over 25 years (MAXIMUM of 7 years):                                                                           D2
          3. TOTAL MONTHLY BENEFIT:                                                                                        D3



Prepared by:                                                     Date:                      Phone:                         <<< Prepared by, Date and Phone
                                          CORRECTIONS OFFICER RETIREMENT PLAN                                     FORM C4N RDROP
                                     3010 E. Camelback Rd. Suite 200, Phoenix, Arizona 85016                                  08/12
                                   PHONE: (602)255-5575 FAX: (602)296-2369 www.psprs.com                               (Page 1 of 2)

                              APPLICATION FOR REVERSE DEFERRED RETIREMENT OPTION PLAN
                                           FOR MEMBERSHIP ON/AFTER 1/1/2012

TO:       Local Retirement Board                                                DATE:
Having completed 25 or more years of credited service and reaching age 52.5 (fifty-two and a half) with the
                                                                ,I
, hereby submit my application for the REVERSE DROP under the terms of the Arizona Corrections Officer Retirement Plan
(A.R.S. 38-885(D)). I am electing to participate in the REVERSE DROP and terminate employment on
                acknowledging that my effective date of retirement will be the first day of the month following my date of the
election (A.R.S. Section 38-885.01(D)(1), with payments beginning on the last business day of that month, provided that my local
board has met and approved my eligibility and pension benefits and submitted my completed and original documents to CORP by
the 10th of the effective month (A.R.S. Section 38-890 and 38-893(D)). I am further designating as my REVERSE DROP
date                                 (This date cannot exceed 60 months prior to my termination of employment or my completion
of 25 years of credited service and age 52.5) (A.R.S. Section 38-885.01(D)(1)). I understand that I will receive benefits from the
system using the factors of credited service and average monthly benefit compensation in effect on the REVERSE DROP date
(A.R.S. SECTION 38-885.01(D)(3)).


Address                                                                      Home Phone Number
                                                                              Cell Phone Number
Email                                                                        Work Phone Number



SPOUSE

Name:                                              Date of Birth:                            Date of Marriage:

Social Security Number:


DEPENDENT CHILDREN
                                                                                                                 Is Child 18-22 and in
NAME                                            DATE OF BIRTH                   DISABLED?                           school fulltime?




NOTE: Please provide a copy of:

                 1. Your Birth Certificate
                 2. Your Marriage Certificate
                 3. Your Spouse's Birth Certificate
                 4. Your Dependent Childrens' Birth Certificates
                 5. If Divorced during period of employment:
                            a. Photocopy of complete Divorce Decree, or
                            b. Certified Copy of Plan-Approved Domestic Relations Order
                 6. Medical Documentation For Disabled Children. (If applicable)


                                                                                             (NOTE: Please complete 2nd page)
                       APPLICATION FOR REVERSE DEFERRED RETIREMENT OPTION PLAN                            FORM C4N RDROP
                                                                                                               (Page 2 of 2)
Member's
Name:                                                            S.S.N.:                                 Date:

Complete each section below, as applicable.

1. LEAVE(S) WITHOUT PAY

       X    None, OR
            During my period of covered service, I was on leave of absence(s) with the employer as stated below:

             Missed Pay Period(s)                             Employer(s)
       1.
       2.
       3.
       4.
       5.


2. INDUSTRIAL LEAVE

       X    None, OR
            During my period of covered service, I was on industrial leave with the employer as stated below:


             FROM (mm-dd-yyyy)                 THROUGH (mm-dd-yyyy)              Employer(s)
       1.
       2.
       3.
       4.
       5.

I hereby submit my application for a deferred annuity subject to all of the terms and conditions of the CORP. I attest that all
information submitted is true, complete and correct to the best of my knowledge and belief. I understand that A.R.S. § 38-
912(C) states: “A person who knowingly makes any false statement or who falsifies or permits to be falsified any record of
the system with an intent to defraud the system is guilty of a class 5 felony.”



                                                                                                                                  <<< Date
             WITNESS SIGNATURE                              MEMBER'S SIGNATURE                                      DATE:




                       EMPLOYER'S CERTIFICATION OF PARTICIPATION IN THE REVERSE DROP

The date that the member elected to participate in the REVERSE DROP
and terminate employment is


By:
                          Signature                 Title
                                        PUBLIC SAFETY PERSONNEL RETIREMENT SYSTEM                                                   FORM C16
                                           CORRECTIONS OFFICER RETIREMENT PLAN                                                          08/12
                                            ELECTED OFFICIALS' RETIREMENT PLAN
                                               3010 East Camelback Road, Suite 200
                                                   Phoenix, Arizona 85016-4416
                                                         www.psprs.com
                                                         (602) 255-5575

                                              CORP RETURN TO WORK ACKNOWLEDGEMENT
               To be completed by the employee at the time of retirement with an effective retirement date on or after 8/1/2012

Section 6109 of the Internal Revenue Code mandates disclosure of your Social Security number (SSN). We will only use your
SSN to obtain account information and to inform the Internal Revenue Service (IRS) of distributions and withholdings.
SECTION 1 - PRINT Member Information
SSN                                 Employer                                                              Retirement Type (Check One)
                                                                                                                 Normal / DROP      Disability
Name(Last)                          (First)                                                               (Middle)



SECTION 2 – INITIAL the Return to Work guidelines pursuant to A.R.S. § 38-884(K):
_____ 1. I have received a copy of the A.R.S. § 38-884 as it relates to the return to the work guidelines which sets forth the terms and
conditions for future employment.

_____ 2. In order for me to continue to receive my pension benefits, I must terminate my employment and be retired for a minimum of one
(1) year from the effective date of my retirement before I return to work in a designated CORP position. If it is determined by the Local Board
and CORP that I can continue to receive my pension benefits, I understand that I cannot contribute to the fund or accrue additional service
credit. I further understand that the employer will be required to pay an “alternate contribution rate” to the CORP based on my gross salary
during the period of reemployment and I will not receive these contributions or accrue additional service credit based on these contributions
when I terminate my reemployment.


_____ 3. If I return to work in a designated CORP position before one (1) year has passed from my date of retirement, my pension benefits
will be suspended. During the period of reemployment, I cannot contribute to the fund or accrue additional service credit. When I resume my
retirement, I will receive the same pension benefit that I was receiving prior to my reemployment. I further understand that the employer will
be required to pay an “alternate contribution rate” to the CORP based on my gross salary during the period of reemployment and I will not
receive these contributions or accrue additional service credit based on these contributions when I terminate my reemployment.


_____ 4. I do not have an implicit, or explicit pre-existing agreement with the employer from which I retired, whether written or verbal, to
return to work after my retirement.

_____ 5. If I am reemployed by an employer, no later than twenty (20) days after the Local Board meeting has taken place, the Local Board
of my new employer shall submit to the CORP the minutes from the Local Board meeting that includes their decision and description of the
action taken and an explanation of the reasons supporting their decision, along with documents pertaining to that decision. I understand that
if the Local Board does not provide the CORP with the necessary documentation to review my return to work eligibility, my retirement benefits
may be suspended pending CORP review.

SECTION 3 – My SIGNATURE below acknowledges that I understand the return to work guidelines as stated above:
PRINT Witness name                                     Witness Signature                                  Date


Member's Signature                                                                                        Date



                   This document is a summary and does not replace statutory provisions, or legislative changes.
  If there are any conflicts, the Arizona Revised Statutes, along with Federal codes for the Internal Revenue Service, shall govern.
                                                                                                              Revised. 08/12
                                                                                                                Page 1 of 2
                         REVERSE DEFERRED RETIREMENT OPTION PLAN
                       MEMORANDUM OF UNDERSTANDING AND AGREEMENT
                                   FOR MEMBERSHIP ON/AFTER 1/1/2012
                           Your Statements to your employer and your CORP Local Board

Your employer and your Local Board will rely on the following facts. Each is important because it demonstrates you
have carefully considered your election to participate in the REVERSE DROP.

Please initial each statement if true in the place shown in the left margin. If the statement is not true and you do not
initial each statement, you cannot enter into the REVERSE DROP.

         I have received a copy of the REVERSE DROP law which sets forth the terms and conditions for participation
         in the REVERSE DROP.

         I have not been subject to any pressure, coercion, intimidation or threats by my employer or the Local Board
         or any of their agents in connection with my election to participate in the REVERSE DROP.

         I have had sufficient time to consider my options regarding my employment with my employer.

         I understand my decision to participate in the REVERSE DROP means I must retire and terminate my
         employment with my employer on the date I elect to participate in the REVERSE DROP.

         I understand there is a maximum period of sixty (60) consecutive months for participation in the REVERSE
         DROP, but in no case can my REVERSE DROP date predate my completion of twenty-five years of credited
         service and age fifty two and a half.

         I understand that my years of service as of my REVERSE DROP date and my average monthly compensation
         as of my REVERSE DROP date will be the factors used in calculating all amounts credited to my REVERSE
         DROP account, as well my monthly pension.

         I understand that all contributions made pursuant to A.R.S. Section 38-891 during the period of the REVERSE
         DROP are not eligible to be refunded.

         I understand my decision to participate in the REVERSE DROP has very important consequences for me. I
         have been advised to consult an advisor such as an accountant or an attorney of my choosing if I have any
         questions about my participation in the REVERSE DROP.

         I understand this agreement has very important consequences for me and is legally binding on me. I have
         been advised to consult an attorney of my choosing if I have any questions about the agreement.

                                            Your promises to your employer

Please initial each statement if true in the place shown in the left margin. If the statement is not true and you do not
initial each statement, you cannot enter into the REVERSE DROP.

         I elect to participate in the REVERSE DROP.

         The number of months in my REVERSE DROP designation period is as prescribed in Form C4 RDROP. (The
         REVERSE DROP designation period may not exceed sixty (60) consecutive months or predate my
         completion of twenty-five years of credited service and age fifty-two and a half.)

         I will retire under the CORP and terminate my employment with my employer on the date I elect to participate
         in REVERSE DROP.

         I will abide by the terms and conditions of REVERSE DROP as prescribed by law.
                                                                                                              Revised. 08/12
                                                                                                                Page 2 of 2
                                                          Waiver

Please initial each statement if true in the place shown in the left margin. If the statement is not true and you do not
initial each statement, you cannot enter into the REVERSE DROP.

         I release my employer, the Local Board and the board of trustees from any and all claims based on my
         election to participate in the REVERSE DROP and my agreement to retire and terminate my employment with
         my employer.

         I release my employer, the Local Board and the board of trustees from any and all claims under the Arizona
         and Federal Age Discrimination in Employment laws and Civil Rights laws as these laws relate to my
         participation in the REVERSE DROP and my agreement to terminate employment with my employer.

         I understand that the facts in respect of which this agreement is made and releases are given may hereafter
         turn out to be other than or different from the facts now known by me or believed by me to be true. I expressly
         accept and assume the risk of the facts turning out to be so different. I agree that any releases I make in this
         agreement shall be in all respects effective and not subject to termination or rescission by reason of any such
         differences in facts.

                                                  Covenant Not To Sue

Please initial each statement if true in the place shown in the left margin. If the statement is not true and you do not
initial each statement, you cannot enter into the REVERSE DROP.

         I will not sue my employer, the Local Board, the board of trustees, or their employees, officers and agents for
         any claim arising out of my election to participate in REVERSE DROP, my participation in the REVERSE
         DROP or my decision to retire and terminate employment with my employer.

                                            Your signature to the Agreement

         I have carefully read this entire agreement.

         I understand this agreement.

         I am satisfied with this agreement.

         I have signed my name voluntarily.

This is the only agreement I have made with my employer and the Local Board regarding my election to participate in
the REVERSE DROP and my agreement to terminate my employment with my employer and retire.

Dated:
                                                                      Member (Print)



                                                                      Member (Signature)

                                                                      Social Security Number


                                                                      Employer Name

Dated:                                                          BY:
                                                                      Employer Signature

Dated:                                                          BY:
                                                                      Local Board Signature
       W-4P                                      Withholding Certificate for
Form
       Substitute                               Pension or Annuity Payments                                                            2012
Purpose. Form W-4P is for U.S. citizens, resident aliens, or                   pages 3 and 4. Your previously filed Form W-4P will remain in
their estates who are recipients of pensions, annuities                        effect if you do not file a Form W-4P for 2012.
(including commercial annuities), and certain other deferred                   What do I need to do? Complete lines A through G of the
compensation. Use Form W-4P to tell payers the correct                         Personal Allowances Worksheet. Use the additional
amount of federal income tax to withhold from your payment(s).                 worksheets on page 2 to further adjust your withholding
You also may use Form W-4P to choose (a) not to have any                       allowances for itemized deductions, adjustments to income, any
federal income tax withheld from the payment (except for                       additional standard deduction, certain credits, or multiple
eligible rollover distributions or payments to U.S. citizens                   pensions/more-than-one-income situations. If you do not want any
delivered outside the United States or its possessions) or (b) to              federal income tax withheld (see Purpose, earlier), you can skip
have an additional amount of tax withheld.                                     the worksheets and go directly to the Form W-4P below.
 Your options depend on whether the payment is periodic,                       Sign this form. Form W-4P is not valid unless you sign it.
nonperiodic, or an eligible rollover distribution, as explained on
                                                       Personal Allowances Worksheet
A    Enter "1" for yourself if no one else can claim you as a dependent                                                                A                     <<< A
                      ● You are single and have only one pension; or
                      ● You are married, have only one pension, and your
B     Enter "1" if:    spouse has no income subject to withholding; or                                                                 B                     <<< B
                      ● Your income from a second pension or a job, or your spouse's
                       pension or wages (or the total of all) is $1,500 or less.
C   Enter "1" for your spouse. But you may choose to enter "-0-" if you are married and have either a spouse who has
    income subject to withhholding, or you have more than one source of income subject to withholding. (Entering
    "-0-" may help you avoid having too little tax withheld.)                                                                          C                     <<< C
D   Enter number of dependents (other than your spouse or yourself) you will claim on your tax return                                  D                     <<< D
E   Enter "1" if you will file as head of household on your tax return                                                                 E                     <<< E
F   Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.
    ● If your total income will be less than $61,000 ($90,000 if married), enter “2” for each eligible child; then less “1” if
      you have three to seven eligible children or less “2” if you have eight or more eligible children.
    ● If your total income will be between $61,000 and $84,000 ($90,000 and $119,000 if married), enter “1” for
      each eligible child.                                                                                                             F
G   Add lines A through F and enter total here. (Note: This may be different from the number of exemptions you claim
    on your tax return.)                                                                                                               G          0
                      ● If you plan to itemize or claim adjustments to income and want to reduce your withholding,
    For                 see the Deductions and Adjustments Worksheet on page 2.
    accuracy,         ● If you are single and have more than one source of income subject to withholding or are
    complete            married and you or your spouse both have income subject to withholding and your
    all                 combined income from all sources exceeds $40,000 ($10,000 if married), see the Multiple
    worksheets          Pensions/More-Than-One-Income Worksheet on page 2 to avoid having too little tax withheld.
    that apply.       ● If neither of the above situations applies, stop here and enter the number from line G on line 2 of
                        Form W-4P below.

                      Cut here and give the certificate to the payer of your pension or annuity. Keep the top part for your records.


                                                 Withholding Certificate for
Form   W-4P                                                                                                                            2012
       Substitute                               Pension or Annuity Payments
Type or print your full name                                                                                      Your social security number


Home address (number and street or rural route)                                                                   Claim or identification number (if
                                                                                                                  any) of your penion or annuity
                                                                                                                  contract
City or town, state, and ZIP code


Complete the following applicable lines:
 1 Check here if you do not want any Federal income tax withheld from your pension or annuity. (Do not complete lines 2 or 3.)
 2 Total number of allowances and marital status you are claiming for withholding from each periodic pension or
   annuity payment. (You may also designate an additional dollar amount on line 3.) . . . . . . . . . . . . . . .                                 0                     <<< Number of Allowances
   Marital status:        Single        Married        Married, but withhold at higher Single rate                                         (Enter number
                                                                                                                                           of allowances.)
 3 Additional amount, if any, you want withheld from each pension or annuity payment. (Note: For periodic payments,
   you cannot enter an amount here without entering the number (including zero) of allowances on line 2) . . . . . . .                                                  <<< Additional Amount

Your signature                                                                                           Date                                                <<< Date
 ARIZONA FORM                                   Annuitant's Request for
       A-4P                            Voluntary Arizona Income Tax Withholding                                                          2012
     SUBSTITUTE

                             NOTE: This form is effective for annuity or pension payments after June 30th 2010.


Type or print your full name (last, first, middle initial)                                   Your Social Security Number


Home address (number and street or rural route)                                              Annuity Contract Claim or I.D. Number


City or town, state, and ZIP code                                                            Telephone Number




                                        Annuitant's Voluntary Arizona Income Tax Withholding Options
Choose only one*:
1.          I hereby elect to have Arizona income taxes withheld from my annuity or pension payments as authorized by ARS §43-404.
           I choose to have Arizona withholding at the rate of
         (Check only one box):             0.8%        1.3%         1.8%         2.7%        3.6%         4.2%        5.1%     of the
           taxable amount of distribution.

              Additional amount to be withheld per distribution $


2.          I hereby elect to terminate my prior election for voluntary Arizona income tax withholding from my annuity or pension payments as
            authorized by ARS §43-404.


I certify that I have made the percentage election marked above.



SIGNATURE                                                                                             DATE



                                                             GENERAL INSTRUCTIONS
Who May Use Form A-4P                                                        Where to Send Form A-4P
A person who receives an annuity or pension may use this                     Send Form A-4P to the payor of your annuity or pension. Do not
form to elect voluntary Arizona income tax withholding.                      send Form A-4P to the Arizona Department of Revenue.
Arizona withholding is a percentage of the amount of the
taxable amount of distribution in Box 2a of federal Form1099-
R. Therefore, you may elect voluntary Arizona income tax                     Duration of Voluntary Arizona Withholding Election
withholding at the applicable percentage rates and designate                 The payor of your pension or annuity will withhold Arizona income
an additional amount to be withheld.                                         tax from your payments until you notify the payor to terminate
                                                                             Arizona withholding.
"Annuity" means any amount paid to an individual as a
pension or annuity, but only to the extent that the amount is                How to Terminate a Voluntary Arizona Withholding Election
includible in the Arizona gross income of that individual.                   You may terminate your voluntary Arizona withholding election at any
                                                                             time. You may use the Form A-4P to terminate Arizona withholding
                                                                             or you may send a written notice to the payor of your pension or
You may NOT elect to have Arizona income tax withheld                        annuity requesting termination of withholding.
from nonperiodic payments, lump sum distributions, or
individual retirement account distributions, that do not meet
the definition of annuity listed above.                                      Statement of Income Tax Withheld
                                                                             The payor of your pension or annuity will provide you with a form that
                                                                             lists the total amount of your pension or annuity payments and the
You also may NOT elect to have Arizona income tax withheld
                                                                             total amount of Arizona income tax withheld from these payments for
from Social Security pensions, Veteran's Administration
                                                                             the current calendar year. The payor of your pension or annuity will
annuities, or Railroad Retirement pensions.
                                                                             provide this form to you early next year.




       ADOR 91-0042 (03)
<<< Option 1

<<< Percentage




<<< Option 2




<<< Date




    ADOR 91-0042 (03)
                                 PUBLIC SAFETY PERSONNEL RETIREMENT SYSTEM                                                         FORM 8
                                    CORRECTIONS OFFICER RETIREMENT PLAN                                                               08/12
                                     ELECTED OFFICIALS' RETIREMENT PLAN                                                          Page 1 of 2
                                         3010 East Camelback Road, Suite 200                                          Mail OR Fax form to:
                                             Phoenix, Arizona 85016-4416                                                Non-retired Fax
                                                    www.psprs.com
                                                                                                                        (602) 296-2368
                                                        (602) 255-5575
                                                                                                                      Retired Members Fax
                                         BENEFICIARY DESIGNATION FORM                                                    (602) 296-2369

Section 6109 of the Internal Revenue Code mandates disclosure of your Social Security number (SSN). We will only use your SSN
to obtain account information and to inform the Internal Revenue Service (IRS) of distributions and withholdings.
SECTION 1 – PRINT Member Information
SSN                                       RET IREE SYSID (if known)                      Apply this request to the following account(s):
                                                                                                 Non_retired           Retired

Date of Birth (MM/DD/YYYY)                E-mail Address (if applicable, the “Members Only” section with psprs.com will also be updated)


Last Name                                           First Name, Middle Initial


Mailing Address - City, State and ZIP                                                    City, State and Zip+4


Home Phone #                              Cell #                                         Work #


SECTION 2 – IMPORTANT Beneficiary Information
• Persuant to statute, an AUTOMATIC survivor benefit will pay your:
       o Eligible Spouse. (If you are currently receiving a monthly benefit, statute requires two consecutive years of marriage.)
       o Eligible Children that are unmarried, under the age of 18, and/or attending full-time school between the ages of 18 to 23, plus
         disabled child(ren) if disability occurred before the age of 23 and who is a dependent of the member.
• If there is no eligible spouse or eligible child(ren), the balance of the applicable contributions, if any, will be paid to the named
  beneficiary(ies) indicated below.
• T o update your beneficiary for your deferred retirement option plan (DROP), complete a DROP Beneficiary Designation form - not this
form.
• NOT E: Divorce automatically terminates the ex-spouse as the member’s beneficiary. T o maintain an ex-spouse as a beneficiary, you
  must complete a Beneficiary Designation Form after the date of divorce.
      Primary Beneficiary Name(s)
SSN                         Name of Beneficiary (Last, First, Middle)                                  Relationship (Check One)
                                                                                                            Spouse      Child         Parent
                                                                                                            Fiancé          Friend    Other

Birth Date                  Mailing Address - City, State and ZIP                                                    T elephone #


Check ONE             Primary               Secondary Beneficiary (If not checked, the following beneficiary is a Primary Beneficiary.)
                                OR
SSN                         Name of Beneficiary (Last, First, Middle)                                  Relationship (Check One)
                                                                                                            Spouse      Child         Parent
                                                                                                            Fiancé          Friend    Other

Birth Date                  Mailing Address - City, State and ZIP                                                    T elephone #


Check ONE             Primary               Secondary Beneficiary (If not checked, the following beneficiary is a Primary Beneficiary.)
                                OR
SSN                         Name of Beneficiary (Last, First, Middle)                                  Relationship (Check One)
                                                                                                            Spouse      Child         Parent
                                                                                                            Fiancé          Friend    Other

Birth Date                  Mailing Address - City, State and ZIP                                                    T elephone #


SECTION 3 – REQUIRED Signatures
PRINT Witness Name: (cannot be beneficiary listed              Witness Signature                                     Date


Member's Signature                                                                                                   Date


               If not prev iously prov ided and signing as Power of Attorney or Guardian, prov ide our office with a complete
                                                          copy of legal appointment.
             For additional beneficiaries, copy and attach this form.     Check this box if there is an additional form attached.
                             PUBLIC SAFETY PERSONNEL RETIREMENT SYSTEM                                FORM U3 - Retired
                                CORRECTIONS OFFICER RETIREMENT PLAN                                              08/12
                                 ELECTED OFFICIALS' RETIREMENT PLAN                                         Page 1 of 2
                                    3010 East Camelback Road, Suite 200
                                        Phoenix, Arizona 85016-4416                                Retired Member's Fax*
                                              www.psprs.com                                           (602) 296-2369
                                              (602) 255-5575


                                     LUMP SUM DISTRIBUTION ELECTION FORM
                          If you are "refunding" your contributions, complete Form U3 Refunds

Name of Recipient:

SSN of Recipient:                                         Date of Retirement / Death:
                                                          (N/A for ex-spouse)

SECTION 1 - Distribution Type (check ONE)

       DROP / DROP Beneficiary / CORP Reverse DROP               OR         Lump-Sum Death Benefit

SECTION 2 - Distribution Method (check ONE)

       TOTAL Distribution to Recipient
        (Sign below and return the original; you do not need to complete page 2 of 2)

        The ENTIRE payment will be made to me less the applicable Federal withholding (generally 20%) based on the
        taxable portion of benefits.
        OR

       Rollover
       Rollover
        (Sign below and complete page 2 of 2)

        I elect to roll ALL or a PORTION of the TAXABLE benefit to the financial institution(s) as indicated below.
        If any portion is NON-TAXABLE, this amount cannot be rolled-over and will be mailed directly to you to the
        address on file. Any amount not stated below will be mailed directly to you less the applicable Federal
        withholding (generally 20%) based on the taxable portion of benefits.

                         List the Financial Institution(s) below                      Indicate a specific amount, or ALL
             and complete the Agreement of Depository Trustee, Page 2 of 2               (taxable amount) to Rollover

        1)
                                                                                     $
        2)
                                                                                     $
        3)
                                                                                     $
               CHECK BOX to SEND BALANCE TO ME less the applicable Federal withholding (generally 20%).


SECTION 3 - REQUIRED SIGNATURE of Member, Survivor / Beneficiary, or Ex-Spouse
I authorize the release of the funds in the manner indicated above and acknowledge I have received a copy of the
Special Tax Notice .


Signature                                                                 Date

                        Return form to your Local Board. (If ex-spouse, return to the PSPRS.)
                      *Benefits will not be paid until the ORIGINAL document(s) are received.
                                 PUBLIC SAFETY PERSONNEL RETIREMENT SYSTEM                                   FORM U3 - Retired
                                    CORRECTIONS OFFICER RETIREMENT PLAN                                                 08/12
                                     ELECTED OFFICIALS' RETIREMENT PLAN                                            Page 2 of 2
                                         3010 East Camelback Road, Suite 200
                                           Phoenix, Arizona 85016-4416                                Retired Member's Fax*
                                                    www.psprs.com                                         (602) 296-2369
                                                   (602) 255-5575



                                           AGREEMENT OF DEPOSITORY TRUSTEE
                     EACH financial institution MUST complete this page (make additional copies as needed)



In accordance with the authorization of the depositor on the corresponding Lump Sum Distribution Election Form for Benefits ,
we agree to deposit the forthcoming rollover amount in the following account:



Type of Account (check one):

    1) Sec 401(a) Qualified Defined Benefit Plan
                                                                                             Name of Acccount Holder
    2) Sec 401(a) Qualified Defined Contribution Plan (Includes Sec 401K)

    3) Sec 403(a) Qualified Annuity Plan
                                                                                                 Account Number
    4) Sec 403(b) Tax Sheltered Annuity

    5) Sec 408(a) Traditional IRA (Includes SEP IRA)

    6) Sec 408(b) Individual Retirement Annuity

    7) Sec 457 Governmental Plan


                         Name of Financial Institution




     Signature of Financial Institution Representative             Date



                               Mailing Address



       City                           State                         Zip

Return form to your Local Board. (If ex-spouse, return to the PSPRS.)
*Benefits will not be paid until the ORIGINAL document(s) are received.

                               Mailing Address

              City                    State                        Zip+4
08/12

				
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