Form PERS050 "Voluntary Employee Savings Plan Enrollment, Change, Discontinuation or Withdrawal (For Pers Tiers I, II & III Active Employees Only)" - Alaska

Form PERS050 or the "Voluntary Employee Savings Plan Enrollment, Change, Discontinuation Or Withdrawal (for Pers Tiers I, Ii & Iii Active Employees Only)" is a form issued by the Alaska Department of Administration.

Download a PDF version of the Form PERS050 down below or find it on the Alaska Department of Administration Forms website.

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Download Form PERS050 "Voluntary Employee Savings Plan Enrollment, Change, Discontinuation or Withdrawal (For Pers Tiers I, II & III Active Employees Only)" - Alaska

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Voluntary Employee Savings Plan
Enrollment, Change,
FOR OFFICE USE ONLY
Discontinuation or Withdrawal
(for PERS Tiers I, II & III Active Employees Only)
Division of Retirement and Benefits
Juneau: (907) 465-4460
Toll-Free: (800) 821-2251
P.O. Box 110203
TDD: (907) 465-2805
alaska.gov/drb
Juneau, Alaska 99811-0203
Fax: (907) 465-3363
SECTION I. PERSONAL DATA
Employee Name Last
First
M.I.
RIN or Last 4 of Social Security Number
Mailing Address Street or P.O. Box
City
State
ZIP+4
Employer (State or Political Subdivision)
Email Address
SECTION II. ELECTION, CHANGES OR DISCONTINUATION
Please note: If you are on a bi-weekly pay schedule, the Voluntary Savings amount will be withheld each pay period. In accordance
with the provisions of the Public Employees' Retirement System Act, I hereby:
T T
Elect to make contributions of $____________. Please specify dollar amount each pay period to Voluntary Savings.
Please note: Employee can only contribute up to 5% of gross salary per pay period.
T T
Please change Voluntary Savings amount from $__________ to $__________. Dollar amount cannot exceed 5% of gross salary
per pay period.
T T
Elect to make _________% of gross salary per pay period. If you choose this option, the amount will be capped at 5%.
T T
Please change my Voluntary Savings contribution from __________% of my gross salary each pay period to ___________% of
gross salary each pay period (can not exceed 5% per pay period).
T T
Discontinue my Voluntary Savings contribution.
Signature
Date
SECTION III. WITHDRAWAL OF VOLUNTARY CONTRIBUTIONS (SEC. 39.35.240)
Please note: When completing the withdrawal portion of this application you must state a financial need.
T T
I hereby apply for a withdrawal of my Voluntary Savings Contributions.
Please state financial need _______________________________________________________________________________
_________________________________________________________________________________________________________________
Note: Interest on Voluntary Contributions is considered income for federal income tax reporting purposes when refunded to you.
Please indicate below whether or not you want taxes withheld from accrued interest on your voluntary contributions. Taxes will be
withheld at a rate of 20%.
T
T
TTYES. Please withhold taxes.
TTNO. Do not withhold taxes.
In completing this form, I acknowledge that a person who knowingly makes a false statement, or falsifies or permits to be falsified,
a record of the retirement system in an attempt to defraud the system, is guilty of a class A misdemeanor, which, upon conviction,
is punishable by a fine of not more than $500.00 or by imprisonment for not more than twelve months or both. AS 39.35.670; AS
11.56.210. I also acknowledge that a person who obtains funds and/or benefits by deception may be subject to prosecution for other
crimes, including theft, which may be charged as misdemeanors or felonies with potential fines and penalties including imprisonment. I
also acknowledge that a person who obtains funds and/or benefits from the system unlawfully may also be required to make restitution.
Signature
Date
FOR OFFICE USE ONLY
Signature of Plan Administrator
Date
pers050 (Rev. 5/15)
G:\Communications_Only\200 Products\206 Forms, Applications, Info Packets, Benefit Cards\PERS\pers050
Voluntary Employee Savings Plan
Enrollment, Change,
FOR OFFICE USE ONLY
Discontinuation or Withdrawal
(for PERS Tiers I, II & III Active Employees Only)
Division of Retirement and Benefits
Juneau: (907) 465-4460
Toll-Free: (800) 821-2251
P.O. Box 110203
TDD: (907) 465-2805
alaska.gov/drb
Juneau, Alaska 99811-0203
Fax: (907) 465-3363
SECTION I. PERSONAL DATA
Employee Name Last
First
M.I.
RIN or Last 4 of Social Security Number
Mailing Address Street or P.O. Box
City
State
ZIP+4
Employer (State or Political Subdivision)
Email Address
SECTION II. ELECTION, CHANGES OR DISCONTINUATION
Please note: If you are on a bi-weekly pay schedule, the Voluntary Savings amount will be withheld each pay period. In accordance
with the provisions of the Public Employees' Retirement System Act, I hereby:
T T
Elect to make contributions of $____________. Please specify dollar amount each pay period to Voluntary Savings.
Please note: Employee can only contribute up to 5% of gross salary per pay period.
T T
Please change Voluntary Savings amount from $__________ to $__________. Dollar amount cannot exceed 5% of gross salary
per pay period.
T T
Elect to make _________% of gross salary per pay period. If you choose this option, the amount will be capped at 5%.
T T
Please change my Voluntary Savings contribution from __________% of my gross salary each pay period to ___________% of
gross salary each pay period (can not exceed 5% per pay period).
T T
Discontinue my Voluntary Savings contribution.
Signature
Date
SECTION III. WITHDRAWAL OF VOLUNTARY CONTRIBUTIONS (SEC. 39.35.240)
Please note: When completing the withdrawal portion of this application you must state a financial need.
T T
I hereby apply for a withdrawal of my Voluntary Savings Contributions.
Please state financial need _______________________________________________________________________________
_________________________________________________________________________________________________________________
Note: Interest on Voluntary Contributions is considered income for federal income tax reporting purposes when refunded to you.
Please indicate below whether or not you want taxes withheld from accrued interest on your voluntary contributions. Taxes will be
withheld at a rate of 20%.
T
T
TTYES. Please withhold taxes.
TTNO. Do not withhold taxes.
In completing this form, I acknowledge that a person who knowingly makes a false statement, or falsifies or permits to be falsified,
a record of the retirement system in an attempt to defraud the system, is guilty of a class A misdemeanor, which, upon conviction,
is punishable by a fine of not more than $500.00 or by imprisonment for not more than twelve months or both. AS 39.35.670; AS
11.56.210. I also acknowledge that a person who obtains funds and/or benefits by deception may be subject to prosecution for other
crimes, including theft, which may be charged as misdemeanors or felonies with potential fines and penalties including imprisonment. I
also acknowledge that a person who obtains funds and/or benefits from the system unlawfully may also be required to make restitution.
Signature
Date
FOR OFFICE USE ONLY
Signature of Plan Administrator
Date
pers050 (Rev. 5/15)
G:\Communications_Only\200 Products\206 Forms, Applications, Info Packets, Benefit Cards\PERS\pers050
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