"Distribution of Judges' Retirement System (Jrs) Extended Service Incentive Program (Esip)" - California

Distribution of Judges' Retirement System (Jrs) Extended Service Incentive Program (Esip) is a legal document that was released by the California Public Employees' Retirement System - a government authority operating within California.

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Download "Distribution of Judges' Retirement System (Jrs) Extended Service Incentive Program (Esip)" - California

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P.O. Box 942705 Sacramento, CA 94229-2705
916-795-3688
TTY: (877) 249-7442 | Fax: 916-795-1500
www.calpers.ca.gov
Judges’ Retirement System
DISTRIBUTION OF JUDGES’ RETIREMENT SYSTEM (JRS)
EXTENDED SERVICE INCENTIVE PROGRAM (ESIP)
Section 1:
Member Information
Note: Name must be the same as the name on your Social Security Card
___________________________________________________________
_______________________________
Name (First Name, Middle Name, Last Name)
Social Security Number or CalPERS ID
___________________________________________ _________________________
___________ ________
Street Address
City
State
Zip Code
______________________________________________ ___________________________________________
Daytime Phone
Evening Phone
Section 2:
In-Hand Distribution and/or Rollover
Please select one of the three options: In-Hand Distribution, rollover, or combination thereof.
Important: For direct rollover financial institution information-do not submit a transfer form that was prepared by your financial institution
in lieu of this completed form.
I elect to receive my entire ESIP account as an “in-hand” distribution.
Federal Tax Withholding
Federal income tax will be withheld at a mandatory rate of 20% of the taxable amount unless you
elect to roll the amount into an IRA account.
State Tax Withholding
Yes- I elect to have 2% of the taxable portion withheld for state income tax.
No-I do not elect to withhold state income tax
Note: If you do not check one of the boxes above, State tax withholding will automatically
be deducted.
I elect to receive a refund as a direct rollover of the taxable portion of my ESIP payment, made
payable to the following financial institution(s). For each separate account, you must indicate the
percentage you wish to go to that account. All accounts must add up to 100%. For additional
accounts, please attach a separate sheet of paper.
My rollover account is an ( ) IRA Account
( ) Other eligible rollover plan
_____________________________________________________
____________________
Name of Financial Institution for IRA Account or Eligible Rollover Plan
Percentage
_________________________________
Account or contract number
My rollover account is an ( ) IRA Account
( ) Other eligible rollover plan
_____________________________________________________
____________________
Name of Financial Institution for IRA Account or Eligible Rollover Plan
Percentage
_________________________________
Account or contract number
Your direct rollover check will be issued in the name of your financial institution but must be mailed to your home address.
You are required to present/deposit the check with your financial institution.
P.O. Box 942705 Sacramento, CA 94229-2705
916-795-3688
TTY: (877) 249-7442 | Fax: 916-795-1500
www.calpers.ca.gov
Judges’ Retirement System
DISTRIBUTION OF JUDGES’ RETIREMENT SYSTEM (JRS)
EXTENDED SERVICE INCENTIVE PROGRAM (ESIP)
Section 1:
Member Information
Note: Name must be the same as the name on your Social Security Card
___________________________________________________________
_______________________________
Name (First Name, Middle Name, Last Name)
Social Security Number or CalPERS ID
___________________________________________ _________________________
___________ ________
Street Address
City
State
Zip Code
______________________________________________ ___________________________________________
Daytime Phone
Evening Phone
Section 2:
In-Hand Distribution and/or Rollover
Please select one of the three options: In-Hand Distribution, rollover, or combination thereof.
Important: For direct rollover financial institution information-do not submit a transfer form that was prepared by your financial institution
in lieu of this completed form.
I elect to receive my entire ESIP account as an “in-hand” distribution.
Federal Tax Withholding
Federal income tax will be withheld at a mandatory rate of 20% of the taxable amount unless you
elect to roll the amount into an IRA account.
State Tax Withholding
Yes- I elect to have 2% of the taxable portion withheld for state income tax.
No-I do not elect to withhold state income tax
Note: If you do not check one of the boxes above, State tax withholding will automatically
be deducted.
I elect to receive a refund as a direct rollover of the taxable portion of my ESIP payment, made
payable to the following financial institution(s). For each separate account, you must indicate the
percentage you wish to go to that account. All accounts must add up to 100%. For additional
accounts, please attach a separate sheet of paper.
My rollover account is an ( ) IRA Account
( ) Other eligible rollover plan
_____________________________________________________
____________________
Name of Financial Institution for IRA Account or Eligible Rollover Plan
Percentage
_________________________________
Account or contract number
My rollover account is an ( ) IRA Account
( ) Other eligible rollover plan
_____________________________________________________
____________________
Name of Financial Institution for IRA Account or Eligible Rollover Plan
Percentage
_________________________________
Account or contract number
Your direct rollover check will be issued in the name of your financial institution but must be mailed to your home address.
You are required to present/deposit the check with your financial institution.
_____________________________________________________________ ________________________________
Name (First Name, Middle Name, Last Name)
Social Security Number or CalPERS ID
Section 2 continued:
In-Hand Distribution and/or Rollover
Please select one of the three options: In-Hand Distribution, rollover, or combination thereof.
Important: For direct rollover financial institution information-do not submit a transfer form that was prepared by your financial institution
in lieu of this completed form.
I elect to receive a combination in-hand distribution and rollover. The amount I want to receive in-
hand (after-taxes) is $______________________
Federal Tax Withholding
Federal income tax will be withheld at a mandatory rate of 20% of the taxable amount unless you
elect to roll the amount into an IRA account.
State Tax Withholding
Yes- I elect to have 2% of the taxable portion withheld for state income tax.
No-I do not elect to withhold state income tax
Note: If you do not check one of the boxes above, State tax withholding will automatically
be deducted.
The rollover portion of my ESIP payment, should be made payable to the following financial
institution(s). For each separate account, you must indicate the percentage you wish to go to
that account. All accounts must add up to 100%. For additional accounts, please attach a
separate sheet of paper.
My rollover account is an ( ) IRA Account
( ) Other eligible rollover plan
_____________________________________________________
____________________
Name of Financial Institution for IRA Account or Eligible Rollover Plan
Percentage
_________________________________
Account or contract number
My rollover account is an ( ) IRA Account
( ) Other eligible rollover plan
_____________________________________________________
____________________
Name of Financial Institution for IRA Account or Eligible Rollover Plan
Percentage
_________________________________
Account or contract number
Your direct rollover check will be issued in the name of your financial institution but must be mailed to your home address.
You are required to present/deposit the check with your financial institution.
_____________________________________________________________ ________________________________
Name (First Name, Middle Name, Last Name)
Social Security Number or CalPERS ID
Section 3:
Member and Spouse/Domestic Partner Signatures
________________________________________________________
_____________________
Member’s Signature
Date (mm/dd/yyyy)
If you are married or have a registered domestic partner, your spouse or registered domestic
partner must also sign this form. Not legally married can mean never married, divorced, or widowed.
You must also complete a Justification for Non Signature of Spouse or Registered Domestic
Partner form (attached) if you are married or in a registered domestic partnership and your spouse
or domestic partner is unable to sign this form.
By signing this form, I acknowledge my spouse’s/registered domestic partner’s request for an ESIP
program payment.
________________________________________________________
_____________________
Spouse/Registered Domestic Partner’s Signature
Date (mm/dd/yyyy)
If no spouse/registered domestic partner signature, check below if the following applies
to you:
I am not legally married or do not have a registered domestic partner.
A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to
which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.
State of California
County of _________________________
On ________________ before me, ___________________________________________, personally appeared,
(Date-mm/dd/yyyy)
(Name & Title of Officer or CalPERS Representative)
_________________________________________________________ who proved to me on the basis of
satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and
acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by
his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted,
executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and
correct.
WITNESS my hand and official seal.
Signature ______________________________________________ (SEAL)
Justification for Non Signature of Spouse or
Registered Domestic Partner
Pursuant to Government Code Section 21261, the member’s current spouse/registered
domestic partner must be made aware of the selection of benefits. The spouse/registered
domestic partner of a member of our System must acknowledge the submission of a
request for lump sum payment or rollover of an ESIP distribution
.
I am not legally married or a have registered domestic partner because:
Never married or had a registered domestic partnership
Divorced/marriage/partnership terminated ___________________/_______/________________
Month
Day
Year
Widowed ___________________/_______/________________
Month
Day
Year
I am married/in a registered domestic partnership, but my spouse/registered domestic partner did not sign the
form because:
I do not know and have taken all reasonable steps to determine the whereabouts of my spouse/
registered domestic partner
My spouse/registered domestic partner has been advised of the application and has refused to sign
the acknowledgement
My spouse/registered domestic partner is incapable of executing the acknowledgement because
of an incapacitating mental or physical condition
My spouse/registered domestic partner has no identifiable community property interest in the benefit.
My spouse/registered domestic partner and I have executed a marriage/partnership settlement
agreement which makes the community property law inapplicable to the marriage/partnership.
I hereby certify, under the penalty of perjury, that the foregoing information is true and correct.
____________________________________________________________ ______________________________
Signature of Member
Date
(mm/dd/yyyy)
Privacy Notice
The privacy of personal information is of the utmost importance to CalPERS.
The following information is provided to you in compliance with the Information
Practices Act of 1977 and the Federal Privacy Act of 1974.
Information Purpose
Social Security numbers are used for the
following purposes:
The information requested is collected pursuant
1.
Enrollee identifcation
to the Government Code (sections 20000 et seq.)
2. Payroll deduction/state contributions
and will be used for administration of Board
3. Billing of contracting agencies for employee/
duties under the Retirement Law, the Social
employer contributions
Security Act, and the Public Employees’ Medical
4. Reports to CalPERS and other state agencies
and Hospital Care Act, as the case may be.
5. Coordination of benefts among carriers
Submission of the requested information is
6. Resolving member appeals, complaints,
mandatory. Failure to comply may result in
or grievances with health plan carriers
CalPERS being unable to perform its functions
regarding your status.
Information Disclosure
Please do not include information that is
Portions of this information may be transferred
not requested.
to other state agencies (such as your employer),
physicians, and insurance carriers, but only
Social Security Numbers
in strict accordance with current statutes
regarding confdentiality.
Social Security numbers are collected on a
mandatory and voluntary basis. If this is CalPERS’
Your Rights
frst request for disclosure of your Social Security
number, then disclosure is mandatory. If your
You have the right to review your membership
Social Security number has already been provided,
fles maintained by the System. For questions
disclosure is voluntary. Due to the use of Social
about this notice, our Privacy Policy, or your rights,
Security numbers by other agencies for
please write to the CalPERS Privacy Ofcer at
identifcation purposes, we may be unable to
400 Q Street, Sacramento, CA 95811 or call us
verify eligibility for benefts without the number.
at 888 CalPERS (or 888-225-7377).
May 2016
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