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Tax Laws on Claiming Children

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					                 PUBLIC SAFETY PERSONNEL RETIREMENT SYSTEM (Version: 12/1/2009)
                                  Normal Retirement - 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.
                                                                           PLEASE SELECT BENEFIT TYPE:
TODAY'S DATE:                                                                 NORMAL RETIREMENT
                                                                              ACCIDENTAL DISABILITY
RETIRE DATE:
                                                                              ORDINARY DISABILITY
Not Applicable
                                                                              CATASTROPHIC DISABILITY        Over 60-months
PERSONAL INFORMATION
                                                                              TEMPORARY DISABILITY
First Name
Middle Name                                                                   SURVIVING SPOUSE          GUARDIAN
Last Name                                                                                                    Member was retired

Social Security No.                                                                                          Killed in line of duty
Sex                                                                           DESIGNATED BENEFICIARY

Member Date of Birth                                                          REPRESENTATIVE OF DECEDENT'S ESTATE

Marital Status                    Single   Married                            DEFERRED ANNUITY

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

CONTACT INFORMATION OF MEMBER
                      Address 1                                      Address 2

          City                   State                       Zip
                                  AZ
 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
Current Employer
  Service      From:                                      Not Applicable
                 To:                                      Not Applicable
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



                                                                                                                               Not Applicable



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 as indicated below:
        From                           Through              Employer                                            NONE
Flat number (years) >>




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




PAYMENT INFORMATION
Payable to
Payment Method

DIRECT DEPOSIT INFORMATION
Financial Institution
Phone Number

MEMBER'S ACCOUNT INFORMATION
Bank ABA Routing #
                                                                Print:       P4       P8      P11         P12    W-4P   A-4P              Form 13
Account Type
Bank Account No.                                                        Normal Retirement: Forms P4, P8, P11, P12 & Tax Forms
BENEFICIARY INFORMATION
Primary Beneficiary(ies)                                                                            Relationship(s)
Date(s) of Birth
Contingent Beneficiary(ies)                                                                         Relationship(s)
Date(s) of Birth

   FORMS PREPARED BY:
       PHONE NUMBER:
                                                                                           Other Things To Print
                      SYS
                        ID
                     NAME
                     PLAN 1
           BENEFIT AMOUNT
                 YRS SERV
               LAW AMEND 68 LAW/ 06 AMEND
             DATE RETIRED
              STATE TAX %
                TERM DATE

                      SYS
                        ID
                     NAME
                      SSN    0
                 ADDRESS
                   ADDR 2
                      CITY
                    STATE    AZ
                       ZIP
                 COUNTRY
                   PHONE
                      SEX
                MEMB DOB     1/0/1900
                  MARITAL    M
              EXEMPTIONS
                 BENTYPE     01
             PERCENT REC     100
                  CHK SAV    00
             ACT INACTIVE    Y
             B TERM CODE     0
     TOTAL CONTRIBUTIONS
NONTAXABLE CONTRIBUTIONS
            DROP MONTHS      0
   For PSPRS Use Only                      PUBLIC SAFETY PERSONNEL RETIREMENT SYSTEM                                          FORM P4
System:                                   3010 E. Camelback Rd. Suite 200, Phoenix, Arizona 85016                                 09/09
I.D. :                                  PHONE: (602)255-5575 FAX: (602)296-2369 www.psprs.com                                Page 1 of 2
Date
Retired:                                          APPLICATION FOR NORMAL RETIREMENT


         TO:   Local Retirement Board                                                        DATE:

Having either (1) reached age 62 with 15 or more years of service OR (2) completed 20 or more years of service at the time of
termination with the (employer name)                                                                               , I, (name)
                                                                        hereby submit my application for normal retirement under the
terms of the Arizona Public Safety Retirement System. I am retiring on (date)                                      , acknowledging that
the effective date of my retirement will be the first day of the month following the date of retirement, with payments beginning on or
about the last day of that month (A.R.S. Section 38-884.A). If application is being made under A.R.S. Section 38-854, please state
prior system law:                                                                                                  .



Address                                                                          Home Phone Number
                                                                                 Work Phone Number
                                              AZ                                  Cell Phone Number
                          (City)            (State)        (Zip)                      Email


                                                                   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.   Copy of Divorce Decree (no split with ex-spouse)
                    6.   Certified Copy of Plan Approved Domestic Relations Order
                    7.   Medical Documentation For Disabled Children. (If applicable)
                    8.   Proof of Fulltime School Enrollment (If applicable)

                                                                                                    (NOTE: Please complete 2nd page)
                                  APPLICATION FOR NORMAL RETIREMENT                                                        FORM P4
                                                                                                                        (Page 2 of 2)

 Name:                                                        Soc. Sec. Num.                        Date:

1. LEAVE(S) WITHOUT PAY: During my period(s) of covered service, I have been on leave of absence without pay as
indicated below:

           (a) None
                              From         Through        Employer
            (b)        1.
                       2.
                       3.
                       4.
                       5.

2. 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:

           (a) None
                              From         Through        Employer
            (b)        1.
                       2.
                       3.
                       4.


3. The information contained above is true, complete and correct to the best of my knowledge and belief. Further, I HEREBY
AUTHORIZE the Local Board, the office of the Fund Manager and/or their authorized designee to procure from my
employer(s) or from any other person, firm or corporation (including any governmental agency or department thereof) any and
all information as directly related to leave(s) of absence without pay and/or application(s) for and/or receipt of Worker's
Compensation Benefits. I expressly waive all provision of law forbidding any doctor, person, firm or corporation (including any
governmental agency or department thereof) from disclosing any knowledge or information which they have in their
possession concerning leave(s) of absence without pay and/or Worker's Compensation.


This is a limited release and is only to be in effect from this date to 120 days after first receipt of my retirement benefits.




                       Witness                                                                 Member's Signature


  Date:


                                   EMPLOYER'S CERTIFICATION OF RETIREMENT DATE:

 Member's employment will terminate                January 0, 1900


                                                                          By:
                                                                                                     Signature

                                                                        Title:
FOR PSPRS USE ONLY                    PUBLIC SAFETY PERSONNEL RETIREMENT SYSTEM                                                FORM P8
SYS:                                 3010 E. Camelback Rd. Suite 200, Phoenix, Arizona 85016                                      09/09
ID:                                                 (602)255-5575 www.psprs.com
                                       Fax: Active (602)296-2368 Fax: Benefits (602)296-2369

                                                  BENEFICIARY DESIGNATION FORM

I,                            , the undersigned, in the event of my death, and after any survivor pension
payable from the plan has terminated, direct that if there remain any of my accumulated contributions arising from
deductions made from my salaries in excess of pension payments paid to me or to a survivor, those remaining
contributions be paid to:

Name(s) of primary refund beneficiary(ies) / Trust                                                                                   ,

whose relationship(s) to me is (are):                                                                                                ,

and whose date(s) of birth (are):                                                                                                    ,

if living, otherwise to:                                                                                                             ,
                                                           Name(s) of contingent refund beneficiary(ies) / Trust

whose relationship(s) to me is (are):                                                                                                ,

and whose date(s) of birth is (are):                                                                                                 .

address and phone number is (are):                                                                                                   .

and social security number is (are):                                                                                                 .


if living, otherwise to my next-of-kin as determined by the Local Retirement Board. It is agreed that if more than one
primary or contingent beneficiary, as the case may be, is named, my said accumulated contributions, if payable, will be
paid in equal shares to the survivors.


DATED THIS                                                       DAY OF                                            ,20



                  WITNESS SIGNATURE                                                               MEMBER (Signature)
      (Witness must be other than beneficiaries named above)
                                                                                                    STREET ADDRESS
Please complete and attach Form P9 if change of beneficiary
reflects a marital status change which involves a name change
of member
                                                                                           CITY             STATE        ZIP


                      Phone Number:                                                         SOCIAL SECURITY NUMBER:

TO THE EMPLOYER:
                                                                                                       EMPLOYER:
Please forward to PSPRS and retain a copy for
your records.
  For PSPRS Use Only              PUBLIC SAFETY PERSONNEL RETIREMENT SYSTEM                                      FORM P11
SYSTEM:                          3010 E. Camelback Rd. Suite 200, Phoenix, Arizona 85016                            09/09
I.D. :                         PHONE: (602)255-5575 FAX: (602)296-2369 www.psprs.com
                                      SERVICE RETIREMENT BENEFIT CALCULATIONS
                                                  A.R.S. Section 38-845
USE THIS PAGE FOR ALL SERVICE RETIREMENTS AND SURVIVING SPOUSE, GUARDIAN AND ELIGIBLE CHILD BENEFITS FOR
DECEASED MEMBERS WHO WERE RECEIVING SERVICE RETIREMENTS

     Member's Name:                                                                     Birth Date:
         Employer:                                                                          S.S.N.:
                Current Employer - YEARS OF SERVICE:
                       plus PRIOR YEARS OF SERVICE:
                           less LEAVES WITHOUT PAY:
                      LENGTH OF CREDITED SERVICE:
                  Amount of Final contribution to PSPRS:                    for Pay Period Ending
A. COMPENSATION: List total compensation for the highest three consecutive years with the last twenty completed years
of credited service (if periods of LWOP and/or Worker's Compensation are included, please indicate on Form 4):




B. TOTAL AMOUNT of highest three consecutive years:
C. AVERAGE MONTHLY COMPENSATION (LINE B / 36 months):
D. For retirement with 20 years of credited service but less than 25 years of credited service
           1. Line C x 50%:
           2. PLUS 2% of Line C for each year of credited
              service over 20 years:
           3. TOTAL MONTHLY BENEFIT:

E. For retirement with 25 or more years of credited service
           1. Line C x 50%:
           2. PLUS 2.5% of Line C for each year of credited service over
              20 years (MAXIMUM of 12 years):
           3. TOTAL MONTHLY BENEFIT:

F. For retirement with 20 years of service but less than 20 years of credited service
           1. Line C x 50%:
           2. MINUS 4% of Line F1 for each year of credited service
              under 20 years:
           3. TOTAL MONTHLY BENEFIT:

G. Surviving spouse or guardian benefit
               4/5 of Line D3, E3 or F3, whichever is applicable:

H. Eligible child benefit
               1/10 of Line D3, E3 or F3, whichever is applicable (MAXIMUM of 2 child shares):                      $0.00
                                                                                                                      total
                                                                                                                    $0.00
                                                                                                                  per child


Prepared by:                                                        Date:                   Phone:
 For PSPRS Use Only              PUBLIC SAFETY PERSONNEL RETIREMENT SYSTEM                                           FORM P12
SYSTEM:                         3010 E. Camelback Rd. Suite 200, Phoenix, Arizona 85016                                 09/09
I.D. :                        PHONE: (602)255-5575 FAX: (602)296-2369 www.psprs.com
BENEFIT
TYPE:          01
DATE
RETIRED:                              NOTIFICATION OF BENEFITS AND ELECTION

 Member's Name:

       Payable to:

  Type of Benefit: Normal                                             Date first payment due:


  1) BENEFITS UNDER ARIZONA PUBLIC SAFETY PERSONNEL RETIREMENT SYSTEM:
      a) Monthly pension payable to member:

      b) Monthly pension payable to surviving spouse or guardian:
         If applicant is a member, the spouse's benefit shown here will be payable upon
         death of the retired member. The spouse's benefit ceases upon death; the
         guardian's benefit ceases when youngest child is no longer eligible. (A.R.S. 38-
         846)

      c) Monthly benefit payable to each eligible child under age 18 and unmarried, or disabled:
           (A.R.S. 38-842)                                                       (Max 2 child shares) Total:
                                                                                          per eligible child: $             -

  2) BENEFITS FROM PRIOR SYSTEMS:

      The applicant may elect to receive the following benefits because of membership in a prior
      retirement system in lieu of the above: (A.R.S. 38-854)

   ***************************************************************************
The Local Retirement Board has determined that the applicant above is eligible for the benefit payments as shown above.




                      Name of Board                                              Signature of Board Chairman or Secretary


   ***************************************************************************
                          ELECTION AND ACCEPTANCE BY MEMBER OR SURVIVOR
                                         (Initial the appropriate line below)
(Initial)
          I ELECT TO ACCEPT the type of pension benefit reflected above as well as the amount of benefits as
          determined under ITEM 1 above, representing the benefits payable to me and to my survivors under the
          Public Safety Personnel Retirement System.

           I ELECT TO RECEIVE the benefits under ITEM 2 in accordance with the prior retirement system
               designated as

I UNDERSTAND that this election to receive benefits pursuant to this document and under the PSPRS or another
system may not be revoked and is binding upon me or any beneficiary or survivor unless otherwise provided by law.


                    Witness                                              Signature of Member, Survivor or Guardian

  Date:
       W-4P                                      Withholding Certificate for
Form
       Substitute                               Pension or Annuity Payments                                                            2010
                                                     States or its possessions) or (b) an                Sign this form. Form W-4P is not valid
Purpose. This form is for recipients of
                                                     additional amount of tax withheld.                  unless you sign it.
pensions, annuities, and certain other
deferred compensation to tell payers                                                                     Other income. If you have a large amount
whether income tax is to be withheld and on          What do I need to do? Complete lines A
                                                     through F of the Personal Allowances                of income from other sources not subject to
what basis. Your options depend on                                                                       withholding (such as interest, dividends, or
whether the payment is periodic,                     Worksheet. Use the additional
                                                     worksheets onpage 2 to adjust your                  taxable social security), consider making
nonperiodic, or an eligible rollover                                                                     estimated tax payments using Form 1040-
distribution as explained on page 3.                 withholding allowances for itemized
                                                     deductions, adjustments to income, or               ES, Estimated Tax for Individuals. Call
  You also may use this form to choose to            multiple pensions/more than one income              1-800-TAX-FORM (1-800-829-3676) for
have (a) no income tax withheld from the             situations. If you do not want income tax           Form 1040-ES, and Pub. 505, Tax
payment (except for eligible rollover                to be withheld, you can skip the                    Withholding and Estimated Tax.
distributions or payments to U.S. citizens           worksheets and go directly to the form at
delivered outside the United                         the bottom of this page.
                                                       Personal Allowances Worksheet
A    Enter "1" for yourself if no one else can claim you as a dependent                                                                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
                      ● 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
D   Enter number of dependents (other than your spouse or yourself) you will claim on your tax return                                  D
E   Enter "1" if you will file as head of household on your tax return                                                                 E
F   Child Tax Credit (including additional child tax credit)
    ● If your total income will be less than $58,000 ($86,000 if married), enter "2" for each eligible child.
    ● If your total income will be between $58,000 and $84,000 ($86,000 and $119,000 if married), enter "1" for
      each eligible child plus "1" additional if you have 4 or more eligible children                                                  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
                      Cut here and give the certificate to the payer of your pension or annuity. Keep the top part for your records.



       W-4P                                      Withholding Certificate for
Form
       Substitute                               Pension or Annuity Payments                                                            2010
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
City or town, state, and ZIP code
                                                                                                                  contract


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.) . . . . . . . . . . . . . . .
   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) . . . . . . .

Your signature                                                                                           Date
 ARIZONA FORM                                         Annuitant's Request for
       A-4P                                  Voluntary Arizona Income Tax Withholding                                                      2010
     SUBSTITUTE

     NOTE: This form is effective for annuity or pension payments after December 31, 2009 through June 30, 2010. A new form will be
     available on the Department’s website (www.azdor.gov) in late spring 2010. You must make a new election for payments after June 30,
     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):           10.7%          20.3%         24.5%         26.7%        33.1%         39.5%     of the federal tax withheld.


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.


*ARIZONA WITHHOLDING MUST BE AT LEAST $5 PER MONTH (OR A PROPORTIONATE RATE FOR ANY SHORTER PAY PERIOD).


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 form                   Send Form A-4P to the payor of your annuity or pension. Do not
to elect voluntary Arizona income tax withholding. Arizona                      send Form A-4P to the Arizona Department of Revenue.
withholding is a percentage of the amount of federal income tax
withheld from the pension or annuity payment. Therefore, you
may elect voluntary Arizona income tax withholding at the                       Duration of Voluntary Arizona Withholding Election
applicable percentage rates only if you have federal income tax                 The payor of your pension or annuity will withhold Arizona income
withheld from the pension or annuity payment. However, if you                   tax from your payments until you notify the payor to terminate
elect voluntary Arizona income tax withholding, the minimum                     Arizona withholding.
amount is $5 per month (or a proportionate rate for any shorter
pay period).                                                                    How to Terminate a Voluntary Arizona Withholding Election
                                                                                You may terminate your voluntary Arizona withholding election at
"Annuity" means any amount paid to an individual as a pension                   any time. You may use the Form A-4P to terminate Arizona
or annuity, but only to the extent that the amount is includible in             withholding or you may send a written notice to the payor of your
the Arizona gross income of that individual. "An amount paid as                 pension or annuity requesting termination of withholding.
a pension or annuity" is an amount received as an annuity under
the provisions of the Internal Revenue Code.                                    Statement of Income Tax Withheld
                                                                                The payor of your pension or annuity will provide you with a form
You may NOT elect to have Arizona income tax withheld from                      that lists the total amount of your pension or annuity payments and
nonperiodic payments, lump sum distributions, or individual                     the total amount of Arizona income tax withheld from these
retirement account distributions, that do not meet the definition               payments for the current calendar year. The payor of your pension
of annuity listed above.                                                        or annuity will provide this form to you early next year.

You also may NOT elect to have Arizona income tax withheld
from Social Security pensions, Veterans Administration
annuities or Railroad Retirement pensions.

       ADOR 91-0042 (03)

				
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Description: Tax Laws on Claiming Children document sample