Form R0311C "Refund Application for Public School Employees" - Michigan

What Is Form R0311C?

This is a legal form that was released by the Michigan Department of Technology Management and Budget - a government authority operating within Michigan. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2018;
  • The latest edition provided by the Michigan Department of Technology Management and Budget;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form R0311C by clicking the link below or browse more documents and templates provided by the Michigan Department of Technology Management and Budget.

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Download Form R0311C "Refund Application for Public School Employees" - Michigan

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Toll Free:
800-381-5111
Local:
517-284-4400
P.O. Box 30171 · Lansing, MI 48909-7671
www.michigan.gov/ors
Fax: 517-284-4416
Refund Application
For Public School Employees
MEMBER’S NAME (LAST, FIRST, M.I.)
DATE OF BIRTH
MEMBER ID OR SSN
MAILING ADDRESS
REPORTING UNIT LAST WORKED
CITY, STATE, ZIP CODE
EMPLOYMENT END DATE
HOME TELEPHONE
(
)
EMAIL ADDRESS
Use this form if your employment has terminated and want to withdraw your pension contributions on account with the retirement
system. This may forfeit your rights to a future pension with the retirement system. See refund instructions before completing. If
you are eligible for a pension and married, you and your spouse must complete the Refund Certification and Spousal Waiver (R0902C).
Section I – Refund Election
.
To be completed by applicant, please select one option from below.
Option 1: I wish to have my refund paid directly to me.
Option 2: I wish to have all previously untaxed pension contributions and interest transferred directly into the qualified
retirement plan or individual retirement account held at ____________________________________________,
and have any previously taxed contributions refunded to me.
Option 3: I wish to have $______________ of my previously untaxed pension contributions and interest transferred into the
retirement plan or individual retirement account held at ____________________________________________.
I wish to have the balance paid directly to me.
Section II – Tax Withholding
ORS will automatically withhold federal income taxes from any amounts paid directly to you.
Check this box if you want Michigan Income tax withheld from your refund.
Section III – Financial Designation.
To be completed by financial institution, if applicant selected option 2 or 3 above. Before
signing, refer to Section III on the back side.
Individual Retirement Account (IRA)
Qualified Plan
TYPE OF ACCOUNT
MAKE CHECK PAYABLE TO (PLAN OR IRA NAME)
ACCOUNT NUMBER
TELEPHONE NUMBER
(
)
MAILING ADDRESS
CITY, STATE, ZIP CODE
TRUSTEE OR PLAN ADMI NISTRATOR SIGNATURE
TRUSTEE NAME OR PLAN ADMINISTRATOR (PRINT)
DATE
Section IV – Employer Certification.
To be completed by the payroll office of the applicant’s last employer, ONLY if employment
ended within the last 6 months. Before signing, refer to Section IV on the back side.
NAME OF REPORTING UNIT
REPORTING UNIT #
TELEPHONE NUMBER
(
)
PAYROLL OFFICIAL’S NAME (PRINT)
DATE CONTRIBUTIONS LAST WITHELD FROM WAGES
PAYROLL OFFICIAL SIGNATURE
TITLE
DATE
Section V – Applicant Certification
.
STOP
Read all instructions and appear before a notary public before signing.
APPLICANT SIGNATURE
DATE
__________________, _________
:
Notary Public
Subscribed and sworn to before me this ____________ day of
County of ___________________ , State of ___________________________
My commission expires ____________________________________________
Notary Signature __________________________________________________
*0000720000000009*
Department of Technology, Management & Budget
R0311C (Rev. 12/2018) Authority: 1980 P.A. 300, as amended
Toll Free:
800-381-5111
Local:
517-284-4400
P.O. Box 30171 · Lansing, MI 48909-7671
www.michigan.gov/ors
Fax: 517-284-4416
Refund Application
For Public School Employees
MEMBER’S NAME (LAST, FIRST, M.I.)
DATE OF BIRTH
MEMBER ID OR SSN
MAILING ADDRESS
REPORTING UNIT LAST WORKED
CITY, STATE, ZIP CODE
EMPLOYMENT END DATE
HOME TELEPHONE
(
)
EMAIL ADDRESS
Use this form if your employment has terminated and want to withdraw your pension contributions on account with the retirement
system. This may forfeit your rights to a future pension with the retirement system. See refund instructions before completing. If
you are eligible for a pension and married, you and your spouse must complete the Refund Certification and Spousal Waiver (R0902C).
Section I – Refund Election
.
To be completed by applicant, please select one option from below.
Option 1: I wish to have my refund paid directly to me.
Option 2: I wish to have all previously untaxed pension contributions and interest transferred directly into the qualified
retirement plan or individual retirement account held at ____________________________________________,
and have any previously taxed contributions refunded to me.
Option 3: I wish to have $______________ of my previously untaxed pension contributions and interest transferred into the
retirement plan or individual retirement account held at ____________________________________________.
I wish to have the balance paid directly to me.
Section II – Tax Withholding
ORS will automatically withhold federal income taxes from any amounts paid directly to you.
Check this box if you want Michigan Income tax withheld from your refund.
Section III – Financial Designation.
To be completed by financial institution, if applicant selected option 2 or 3 above. Before
signing, refer to Section III on the back side.
Individual Retirement Account (IRA)
Qualified Plan
TYPE OF ACCOUNT
MAKE CHECK PAYABLE TO (PLAN OR IRA NAME)
ACCOUNT NUMBER
TELEPHONE NUMBER
(
)
MAILING ADDRESS
CITY, STATE, ZIP CODE
TRUSTEE OR PLAN ADMI NISTRATOR SIGNATURE
TRUSTEE NAME OR PLAN ADMINISTRATOR (PRINT)
DATE
Section IV – Employer Certification.
To be completed by the payroll office of the applicant’s last employer, ONLY if employment
ended within the last 6 months. Before signing, refer to Section IV on the back side.
NAME OF REPORTING UNIT
REPORTING UNIT #
TELEPHONE NUMBER
(
)
PAYROLL OFFICIAL’S NAME (PRINT)
DATE CONTRIBUTIONS LAST WITHELD FROM WAGES
PAYROLL OFFICIAL SIGNATURE
TITLE
DATE
Section V – Applicant Certification
.
STOP
Read all instructions and appear before a notary public before signing.
APPLICANT SIGNATURE
DATE
__________________, _________
:
Notary Public
Subscribed and sworn to before me this ____________ day of
County of ___________________ , State of ___________________________
My commission expires ____________________________________________
Notary Signature __________________________________________________
*0000720000000009*
Department of Technology, Management & Budget
R0311C (Rev. 12/2018) Authority: 1980 P.A. 300, as amended
Refund Application- For Public School Employees
Instructions
Section I – Refund Election.
For more information on the Michigan income tax withholding
Select one option. If you
choose option 1 or 3, 20 percent of the previously untaxed
rules, contact the Michigan Department of Treasury at
www.michigan.gov/taxes.
contributions and interest will be withheld as federal income
tax. If you chose option 2 or 3, your plan administrator must
Section III – Financial Designation.
The plan
complete Section II.
administrator must complete this if option 2 or 3 in Section I is
Section II -Tax Withholding.
selected.
Taking a refund could
affect your taxes. The following is only a summary of tax
Plan administrator: After completing Section III, return the
rules that may apply to your refund. Contact the IRS, the
form to the refund applicant. In accordance with the
Michigan Department of Treasury, or consult a tax
authorization in Section I, you agree to deposit the
advisor for more information.
forthcoming rollover amount from the retirement system into
the stated account. Please understand the transfer may take
We are required to withhold federal income tax from your
up to 90 days to process.
refund under certain circumstances. Your refund may also be
subject to Michigan income tax.
Section IV – Employer Certification.
A payroll official
from the applicant’s last public school employer must
If your employment has terminated, you can have all or any
portion of your refund of previously untaxed money either
complete this if employment ended within the last 6 months.
transferred to a qualified plan or paid directly to you. A
Payroll official: After completing Section IV, return form to
qualified plan is a payment of your refund to your individual
refund applicant. By signing this form, you certify that the
retirement account (IRA) or to another employer plan. How
applicant has ceased all employment in this reporting unit, is
your refund is paid to you will affect the tax you owe.
not on leave of absence, is not on layoff expected to last less
If you choose a qualified plan-to-plan transfer, your refund
than 12 months, will not be offered a substitute (temporary)
will not be taxed in the current year and no income tax will be
position within the next 12 months, or has elected to
withheld. Your refund will be paid directly to your IRA or, if
participate in the Optional Retirement Plan.
you choose, to another employer plan that accepts your
.
Section V– Applicant Certification
rollover. Your refund will be taxed later, when you withdraw it
By signing this form, you agree to the following terms.
from the IRA or the employer plan.
I certify I have ceased employment in all public-
If you choose to have your refund paid directly to you,
supported educational institutions under this retirement
you will receive only 80 percent of the refund. The retirement
system, am not on a leave of absence, am not on a layoff
system is required to withhold 20 percent of the refund and
expected to last 12 months or less, will not be obtaining a
send it to the IRS as federal income tax withholding to be
substitute (temporary) position within the next 12 months,
credited against your taxes. Your refund may also be subject
or I have elected to participate in an Optional Retirement
to Michigan income tax withholding. Your refund will be taxed
Plan. I request that the accumulated balance in my
in the current year unless you transfer it to a qualified plan.
account plus interest be refunded as indicated in Section
You may be able to use special tax rules that could reduce
I. I understand once a refund is processed, it cannot be
the tax you owe. However, if you receive the refund before
cancelled.
age 59½, you may also have to pay an additional 10 percent
tax.
I realize I am giving up my retirement rights accumulated
under the contributory plan and release the Michigan
If you choose to receive your refund directly and later
Public School Employees Retirement System from any
wish to transfer it into your IRA or other employer plan,
claim of accumulated benefits under the contributory plan
you may do so within 60 days of receiving your refund. The
and hereby forfeit all such rights and benefits. If I am
amount transferred will not be taxed until you take it out of
married, I will also complete and submit the Refund
your IRA or employer plan. If you want to transfer 100
Certification and Spousal Waiver (R0902C).
percent of your refund to an IRA or an employer plan, you
must find other money to replace the 20 percent that was
Mail your completed application to:
withheld. If you transfer only the 80 percent that you
Office of Retirement Services
received, you will be taxed on the 20 percent that was
P.O. Box 30171
withheld and not rolled over.
Lansing, MI 48909-7671
You can find specific information on the tax treatment of
Or fax to: (517) 284-4416
payments from qualified retirement plans in IRS publication
You will receive your refund within 90 days from the date
575, Pension and Annuity Income, or IRS Publication 590,
ORS receives your completed application.
Individual Retirement Accounts. You can download these
forms at www.irs.gov,or call 1-800-TAX-FORMS.
Note: If your application is incomplete, we will return it to you
to correct.
R0311C (Rev. 12/2018)
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