Form 5 Refund Application

Public Employees’ Retirement System of Mississippi

429 Mississippi Street, Jackson, MS 39201-1005 800.444.7377 601.359.3589 601.359.5261, fax www.pers.ms.gov

Member Refund Application

Form 5 – Revised 03/14/2022

Please print or type in black ink. Completed form should be mailed or faxed to PERS. See bottom of form for contact information. Refunds

are processed within 90 days of receipt of completed application or termination from last covered employment, whichever is later.

 Member Information – Please provide mailing address where refund check should be sent.

First Name: _______________________________________ MI: ______ Last Name: ______________________________________ Gender:  M  F

Social Security No.: __________________________ Birth Date mm/dd/ccyy: _____________________ E-Mail: __________________________________

Mailing Address: ___________________________________________ City: ___________________________ State: ________ Zip: _______________

Phone: _______________________________  Cellular  Home  Work Phone: _______________________________  Cellular  Home  Work

 Retirement Plan – Plans are governmental defined benefit plans qualified under Section 401(a) of the Internal Revenue Code. Select applicable plan.

 Public Employees’ Retirement System of Mississippi (PERS)  Mississippi Highway Safety Patrol Retirement System (MHSPRS)

 Supplemental Legislative Retirement Plan (SLRP)  Municipal Retirement Systems (MRS) City: ________________________________

 Lump Sum Distribution Election – Select one.

____ Refund to Member

A mandatory 20% federal tax will be withheld from the taxable portion of the payment. I understand that this mandatory withholding may not represent

my actual tax liability and that this payment may be subject to an additional federal tax equal to 10% of the taxable portion if the payment is received

after separation from service but before age 55 or if the payment is received before age 50 for a public safety employee (any employee of a state or

political subdivision who provides police protection, firefighter services, or emergency medical services). To withhold additional federal taxes, please

complete IRS Form W-4R.

____ Rollover Distribution

If this option is chosen, you and your trustee/custodian must complete Form 5C, Rollover Distribution Election. (The transfer/acceptance letter of your

trustee/custodian will not be accepted in lieu of the Form 5C.)

 Applicant Authorization

I acknowledge that I have received the Special Tax Notice Regarding Plan Payments. In consideration of the return of my accumulated contributions, I waive

and relinquish for myself, my heirs, and my assigns, all accrued vested rights in the retirement plan noted above. I also understand that all creditable service

is forfeited by acceptance of this refund.

I further understand that, if I reenter covered service and become a contributing member of PERS or SLRP again, I may repay this refund immediately upon

my return to covered service; however, I must contribute to the applicable retirement plan for a minimum of eight years after returning to covered employment

to restore the associated creditable service and to qualify for certain statutory benefits.

If an authorized representative signs this form, attach a copy of the Durable Power of Attorney, Conservatorship or Guardianship papers, or other legal

documents as proof of authority to sign this form.

Applicant’s Signature: _____________________________________________________________________ Date mm/dd/ccyy:______________________

 Employer Certification – This section must be completed by an authorized employer representative, not the member. Employer certification is required

if date of termination is within one year of the date that this application is executed. In the case of public safety employees who separate from service on or

after age 50 but before age 55, employer certification is required regardless of the period of time that has elapsed since the date of termination.

Member’s Position Held/Job Title: _______________________________________  Elected Official  Fee Paid Official  Public Safety Employee

Member’s Unreported Gross Earnings Date mm/ccyy Member’s Official Dates mm/dd/ccyy: Hire: ____________ Termination: ___________

$ _________________________________ ____________ Leave Accrual Rate at Termination:  Annual  Monthly ___________  Hours  Days

$ _________________________________ ____________ Member’s Accumulated Unused, Uncompensated Personal and Major Medical Leave:

$ _________________________________ ____________ ____________ Hours  Days

Employer Name: ____________________________________________________________ Employer Identification No.: _____________ - ____________

Employer Representative’s Name: ________________________________ Employer Representative’s Title: _____________________________________

Employer Representative’s Phone: _________________________ Fax: __________________________ E-Mail: __________________________________

As employer representative, I understand that any person who makes a false statement or shall falsify or permit to be falsified any record of a retirement plan

administered by PERS in attempt to defraud the plan may be subject to criminal prosecution. With that understanding, I certify that the above employer

certification information is true and correct.

Employer Representative’s Signature: _________________________________________________________ Date mm/dd/ccyy: _____________________

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Reset Form

Public Employees’ Retirement System of Mississippi

429 Mississippi Street, Jackson, MS 39201-1005 800.444.7377 601.359.3589 601.359.5261, fax www.pers.ms.gov

Special Tax Notice Regarding Plan Payments

Your Rollover Options

You are receiving this notice because all or a portion of a payment you are receiving from the Public Employees’ Retirement System of Mississippi (the

Plan) is eligible to be rolled over to an IRA or an employer plan. This notice is intended to help you decide whether to do such a rollover.

This notice describes the rollover rules that apply to payments from the Plan that are not from a designated Roth account (a type of account with special

tax rules in some employer plans). If you also receive a payment from a designated Roth account in the Plan, you will be provided a different notice for

that payment, and the Plan administrator or the payor will tell you the amount that is being paid from each account.

Rules that apply to most payments from a plan are described in the “General Information about Rollovers” section. Special rules that only apply in

certain circumstances are described in the “Special Rules and Options” section.

General Information about Rollovers

How can a rollover affect my taxes?

You will be taxed on a payment from the Plan if you do not roll it over. If you are under age 59½ and do not do a rollover, you also will have to pay a

10% additional income tax on early distributions (unless an exception applies). However, if you do a rollover, you will not have to pay tax until you

receive payments later and the 10% additional income tax will not apply if those payments are made after you are age 59½ (or if an exception

applies).

Where may I roll over the payment?

You may roll over the payment to either an IRA (an individual retirement account or individual retirement annuity) or an employer plan (a tax-

qualified plan, section 403(b) plan, or governmental section 457(b) plan) that will accept the rollover. The rules of the IRA or employer plan that

holds the rollover will determine your investment options, fees, and rights to payment from the IRA or employer plan (for example, no spousal

consent rules apply to IRAs and IRAs may not provide loans). Further, the amount rolled over will become subject to the tax rules that apply to the

IRA or employer plan.

How do I do a rollover?

There are two ways to do a rollover. You can do either a direct rollover or a 60-day rollover.

If you do a direct rollover, the Plan will make the payment directly to your IRA or an employer plan. You should contact the IRA sponsor or

the administrator of the employer plan for information on how to do a direct rollover.

If you do not do a direct rollover, you may still do a rollover by making a deposit into an IRA or eligible employer plan that will accept it. You

will have 60 days after you receive the payment to make the deposit. If you do not do a direct rollover, the Plan is required to withhold 20% of

the payment for federal income taxes (up to the amount of cash and property received other than employer stock). This means that, in order to

roll over the entire payment in a 60-day rollover, you must use other funds to make up for the 20% withheld. If you do not roll over the entire

amount of the payment, the portion not rolled over will be taxed and will be subject to the 10% additional income tax on early distributions if

you are under age 59½ (unless an exception applies).

How much may I roll over?

If you wish to do a rollover, you may roll over all or part of the amount eligible for rollover. Any payment from the Plan is eligible for rollover, except:

• Certain payments spread over a period of at least 10 years or over your life or life expectancy (or the lives or joint life expectancy of you and

your beneficiary)

• Required minimum distributions after age 70½ (or after death)

The Plan administrator or the payor can tell you what portion of a payment is eligible for rollover.

If I don’t do a rollover, will I have to pay the 10% additional income tax on early distributions?

If you are under age 59½, you will have to pay the 10% additional income tax on early distributions for any payment from the Plan (including

amounts withheld for income tax) that you do not roll over, unless one of the exceptions listed below applies. This tax is in addition to the regular

income tax on the payment not rolled over.

The 10% additional income tax does not apply to the following payments from the Plan:

• Payments made after you separate from service if you will be at least age 55 in the year of the separation

• Payments that start after you separate from service if paid at least annually in equal or close to equal amounts over your life or life

expectancy (or the lives or joint life expectancy of you and your beneficiary)

• Payments from a governmental defined benefit pension plan made after you separate from service if you are a public safety employee (any

employee of a state or political subdivision who provides police protection, firefighter services, or emergency medical services) and you are

at least age 50 in the year of the separation

• Payments made due to disability

• Payments after your death

• Payments made directly to the government to satisfy a federal tax levy

• Payments up to the amount of your deductible medical expenses

• Certain payments made while you are on active duty if you were a member of a reserve component called to duty after September 11,

2001, for more than 179 days

Page 2 of 4

Public Employees’ Retirement System of Mississippi

429 Mississippi Street, Jackson, MS 39201-1005 800.444.7377 601.359.3589 601.359.5261, fax www.pers.ms.gov

If I do a rollover to an IRA, will the 10% additional income tax apply to early distributions from the IRA?

If you receive a payment from an IRA when you are under age 59½, you will have to pay the 10% additional income tax on early distributions from

the IRA, unless an exception applies. In general, the exceptions to the 10% additional income tax for early distributions from an IRA are the same

as the preceding exceptions listed for early distributions from a plan. However, there are a few differences for payments from an IRA, including:

• There is no exception for payments after separation from service that are made after age 55.

• The exception for qualified domestic relations orders (QDROs) does not apply (although a special rule applies under which, as part of a

divorce or separation agreement, a tax-free transfer may be made directly to an IRA of a spouse or former spouse).

• The exception for payments made at least annually in equal or close to equal amounts over a specified period applies without regard to

whether you have had a separation from service.

• There are additional exceptions for (1) payments for qualified higher education expenses, (2) payments up to $10,000 used in a qualified

first-time home purchase, and (3) payments after you have received unemployment compensation for 12 consecutive weeks (or would have

been eligible to receive unemployment compensation but for self-employed status).

Will I owe State income taxes?

This notice does not describe any State or local income tax rules (including withholding rules).

Special Rules and Options

If your payment includes after-tax contributions

After-tax contributions included in a payment are not taxed. If a payment is only part of your benefit, an allocable portion of your after-tax

contributions is generally included in the payment. If you have pre-1987 after-tax contributions maintained in a separate account, a special rule may

apply to determine whether the after-tax contributions are included in a payment.

You may roll over to an IRA a payment that includes after-tax contributions through either a direct rollover or a 60-day rollover. You must keep track

of the aggregate amount of the after-tax contributions in all of your IRAs (in order to determine your taxable income for later payments from the

IRAs). If you do a direct rollover of only a portion of the amount paid from the Plan and a portion is paid to you, each of the payments will include an

allocable portion of the after-tax contributions. If you do a 60-day rollover to an IRA of only a portion of the payment made to you, the after-tax

contributions are treated as rolled over last. For example, assume you are receiving a complete distribution of your benefit that totals $12,000, of

which $2,000 is after-tax contributions. In this case, if you roll over $10,000 to an IRA in a 60-day rollover, no amount is taxable because the $2,000

amount not rolled over is treated as being after-tax contributions.

You may roll over to an employer plan all of a payment that includes after-tax contributions, but only through a direct rollover (and only if the

receiving plan separately accounts for after-tax contributions and is not a governmental section 457(b) plan). You can do a 60-day rollover to an

employer plan of part of a payment that includes after-tax contributions, but only up to the amount of the payment that would be taxable if not rolled

over.

If you miss the 60-day rollover deadline

Generally, the 60-day rollover deadline cannot be extended. However, the IRS has the limited authority to waive the deadline under certain

circumstances. To apply for a waiver, you must file a private letter ruling request with the IRS or self-certify. For more information, see IRS

Publication 590-A, Individual Retirement Arrangements (IRAs).

If you were born on or before January 1, 1936

If you were born on or before January 1, 1936, and receive a lump sum distribution that you do not roll over, special rules for calculating the amount

of the tax on the payment might apply to you. For more information, see IRS Publication 575, Pension and Annuity Income.

If you are an eligible retired public safety officer and your pension payment is used to pay for health coverage or qualified

long-term care insurance

If the Plan is a governmental plan, you retired as a public safety officer, and your retirement was by reason of disability or was after normal

retirement age, you can exclude from your taxable income plan payments paid directly as premiums to an accident or health plan (or a qualified

long-term care insurance contract) that your employer maintains for you, your spouse, or your dependents, up to a maximum of $3,000 annually.

For this purpose, a public safety officer is a law enforcement officer, firefighter, chaplain, or member of a rescue squad or ambulance crew.

If you roll over your payment to a Roth IRA

You can roll over a payment from the Plan made before January 1, 2010, to a Roth IRA only if your modified adjusted gross income is not more

than $100,000 for the year the payment is made to you and, if married, you file a joint return. These limitations do not apply to payments made to

you from the Plan after 2009. If you wish to roll over the payment to a Roth IRA, but you are not eligible to do a rollover to a Roth IRA until after

2009, you can do a rollover to a traditional IRA and then, after 2009, elect to convert the traditional IRA into a Roth IRA.

If you roll over the payment to a Roth IRA, a special rule applies under which the amount of the payment rolled over (reduced by any after-tax

amounts) will be taxed. However, the 10% additional income tax on early distributions will not apply (unless you take the amount rolled over out of

the Roth IRA within five years, counting from January 1 of the year of the rollover). For payments from the Plan during 2010 that are rolled over to a

Roth IRA, the taxable amount can be spread over a two-year period starting in 2011.

If you roll over the payment to a Roth IRA, later payments from the Roth IRA that are qualified distributions will not be taxed (including earnings

after the rollover). A qualified distribution from a Roth IRA is a payment made after you are age 59½ (or after your death or disability, or as a

qualified first-time homebuyer distribution of up to $10,000) and after you have had a Roth IRA for at least five years. In applying this 5-year rule,

you count from January 1 of the year for which your first contribution was made to a Roth IRA. Payments from the Roth IRA that are not qualified

distributions will be taxed to the extent of earnings after the rollover, including the 10% additional income tax on early distributions (unless an

exception applies). You do not have to take required minimum distributions from a Roth IRA during your lifetime. For more information, see IRS

Publication 590, Individual Retirement Arrangements (IRAs).

You cannot roll over a payment from the Plan to a designated Roth account in an employer plan.

Page 3 of 4

Public Employees’ Retirement System of Mississippi

429 Mississippi Street, Jackson, MS 39201-1005 800.444.7377 601.359.3589 601.359.5261, fax www.pers.ms.gov

If you are not a plan participant

Payments after death of the participant. If you receive a distribution after the participant’s death that you do not roll over, the distribution will

generally be taxed in the same manner described elsewhere in this notice. However, the 10% additional income tax on early distributions and the

special rules for public safety officers do not apply, and the special rule described under the section “If you were born on or before January 1, 1936”

applies only if the participant was born on or before January 1, 1936.

If you are a surviving spouse. If you receive a payment from the Plan as the surviving spouse of a deceased participant, you have the same

rollover options that the participant would have had, as described elsewhere in this notice. In addition, if you choose to do a rollover to an IRA,

you may treat the IRA as your own or as an inherited IRA.

An IRA you treat as your own is treated like any other IRA of yours, so that payments made to you before you are age 59½ will be subject to

the 10% additional income tax on early distributions (unless an exception applies) and required minimum distributions from your IRA do not

have to start until after you are age 70½.

If you treat the IRA as an inherited IRA, payments from the IRA will not be subject to the 10% additional income tax on early distributions.

However, if the participant had started taking required minimum distributions, you will have to receive required minimum distributions from the

inherited IRA. If the participant had not started taking required minimum distributions from the Plan, you will not have to start receiving required

minimum distributions from the inherited IRA until the year the participant would have been age 70½.

If you are a surviving beneficiary other than a spouse. If you receive a payment from the Plan because of the participant’s death and you

are a designated beneficiary other than a surviving spouse, the only rollover option you have is to do a direct rollover to an inherited IRA.

Payments from the inherited IRA will not be subject to the 10% additional income tax on early distributions. You will have to receive required

minimum distributions from the inherited IRA.

If you are a nonresident alien

If you are a nonresident alien and you do not do a direct rollover to a U.S. IRA or U.S. employer plan, instead of withholding 20%, the Plan is

generally required to withhold 30% of the payment for federal income taxes. If the amount withheld exceeds the amount of tax you owe (as may

happen if you do a 60-day rollover), you may request an income tax refund by filing Form 1040NR and attaching your Form 1042-S. See Form W-

8BEN for claiming that you are entitled to a reduced rate of withholding under an income tax treaty. For more information, see also IRS Publication

519, U.S. Tax Guide for Aliens, and IRS Publication 515, Withholding of Tax on Nonresident Aliens and Foreign Entities.

Other special rules

If a payment is one in a series of payments for less than 10 years, your choice whether to make a direct rollover will apply to all later payments in

the series (unless you make a different choice for later payments).

If your payments for the year are less than $200 (not including payments from a designated Roth account in the Plan), the Plan is not required to

allow you to do a direct rollover and is not required to withhold for federal income taxes. However, you may do a 60-day rollover.

Unless you elect otherwise, a mandatory cashout of more than $1,000 (not including payments from a designated Roth account in the Plan) will be

directly rolled over to an IRA chosen by the Plan administrator or the payor. A mandatory cashout is a payment from a plan to a participant made

before age 62 (or normal retirement age, if later) and without consent, where the participant’s benefit does not exceed $5,000 (not including any

amounts held under the plan as a result of a prior rollover made to the plan).

You may have special rollover rights if you recently served in the U.S. Armed Forces. For more information, see IRS Publication 3, Armed Forces’

Tax Guide.

For More Information

You may wish to consult with the Plan administrator or payor, or a professional tax advisor, before taking a payment from the Plan. Also, you can

find more detailed information on the federal tax treatment of payments from employer plans in: IRS Publication 575, Pension and Annuity Income;

IRS Publication 590, Individual Retirement Arrangements (IRAs); and IRS Publication 571, Tax-Sheltered Annuity Plans (403(b) Plans). These

publications are available from a local IRS office, on the web at www.irs.gov, or by calling 1-800-TAX-FORM.

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