R e t i r e m e n t C o o r d i n a t o r 8R

State Employees’ Retirement SystemSt a t e Ret i re m e nt Sy st e m s

R e t i r e m e n t

M a n u a l

C o o r d i n a t o r

2 0 1 8SRS.ILLINOIS.GOV

For Tier 1 & Tier 2 Employees

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1 - General SERS Information ........................................... 1 Contacting SERS .....................................................................2 Contact information .................................................................3 Additional resources .................................................................3 Designating an agency head or administrator .........................4 Designating a retirement coordinator ......................................4 Designating a payroll coordinator and/or signature designee ....................................................................4 Forms ........................................................................................4 Tiers .........................................................................................5 Retirement formulas .................................................................5 Coordinated vs. noncoordinated ..............................................5 Contributions ...........................................................................5 Member identification ..............................................................6 Membership record ..................................................................6

2 - Retirement coordinator Responsibilities ............................................................. 7

Preparation & identification of documents ..............................9 Distributing retirement plan materials .....................................9 False statements ........................................................................9 Confidential information .........................................................9

3 - Member Responsibilities ............................................ 11 Appeals and hearings before the Board of Trustees ..............13 Forfeit of benefits ...................................................................13 Name and address changes ....................................................13 Beneficiary changes ................................................................13 Correspondence .....................................................................13 Qualified Illinois Domestic Relations Orders (QILDRO) .....14 Rollovers into the SERS defined benefit plan ........................14

4 - Service Credit .............................................................. 15 Purchasing service credit for periods when members did not contribute ...................................................................17 Military service .......................................................................18 Purchasing service credit for periods when members’ contributions were refunded...................................................18 Miscellaneous service credit purchases ..................................19 Payment methods for purchasing service credit .....................19 Sick, vacation and personal time ............................................19 Vacation leave ........................................................................20 Reciprocity .............................................................................20 Reciprocal systems .................................................................20

5 - Refunds ........................................................................ 21 Repayment of refunds ............................................................24

6 - Disability Benefit Claims ............................................ 25 Claim notification...................................................................27 Birth certificate .......................................................................27 Nonoccupational disability benefits .......................................27 Applying for nonoccupational disability benefits ...................28 Occupational disability benefits .............................................28 Temporary disability ..............................................................29

Applying for temporary disability benefits .............................29

7 - Retirement Pension Eligibility .................................... 31 Retirement under regular formula .........................................33 Tier 1 ......................................................................................33 Tier 2 .....................................................................................33 Retirement under alternative formula ...................................34 Tier 1 ......................................................................................34 Tier 2 ......................................................................................34

8 - Death Benefit Claims .................................................. 37 Nonoccupational death benefits .............................................39 Survivor benefits .....................................................................39 Death after retirement ............................................................40 Death after termination .........................................................40 Occupational death benefits ...................................................40 Occupational survivor benefits ...............................................40

9 - Additional Benefit Information ................................... 41 State group insurance .............................................................43 Survivor insurance benefits ....................................................43 Other insurance .....................................................................43 Tax information .....................................................................43 Taxation of benefits ...............................................................43 Taxation of pensions ..............................................................43 Taxation of disability benefits ................................................43 Taxation of survivors/widow’s benefits .................................44 Lump-sum payments ..............................................................44 Rollovers .................................................................................44 10% Early Distribution Tax on lump-sum distributions ........44 Social Security planning .........................................................45 Social Security benefits ..........................................................45 Social Security & SERS disability ..........................................45 Social Security death benefits.................................................45 Social Security retirement benefits .........................................46

10 - Sources of Communication ...................................... 47 Annual Benefit Statement ......................................................49 SERS Handbook (Tier 1 & 2) ................................................49 SERS Newsletters ..................................................................49 NewsFlash ..............................................................................49 SERS Field Representatives ...................................................49 Preretirement workshops ........................................................50 State Police workshops ...........................................................50 Annuitant workshops ..............................................................50 Workshop reservation process ................................................51 Workshop attendance .............................................................52

11 - Appendix .................................................................... 53 Communications ....................................................................55 Service forms ..........................................................................60 Refund forms ..........................................................................64 Disability forms ......................................................................65 Pensions forms ........................................................................80 Miscellaneous forms ...............................................................86

TABLE OF CONTENTS

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The Retirement coordinator is the liaison between the State Employees' Retirement System (SERS) and our active members. SERS expects the Retirement coordinator to complete all required forms in a prompt and efficient manner.

General SERS Information

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CITY OF SPRINGFIELD

North

to Athens

to Jacksonville

to Petersburg

to Chatham

to St. Louis

to Taylorville

to Decatur

to Clinton

to Chicago

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Capitol Airport

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Sangamon

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Def. Comp.201 E. Madison

TRS2815 W. Washington

SRS2101 S. Veterans White

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Social Security3112 Constitution

Contacting SERSState Employees’ Retirement System – Springfield office2101 South Veterans Parkway P. O. Box 19255 Springfield, IL 62794-9255

217-785-7444 Fax: 217-785-7019

[email protected]

State Employees’ Retirement System – Chicago officeMichael Bilandic Building160 North LaSalle, Suite N-725 Chicago, IL 60601

312-814-5853 Fax: 312-814-5805

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CONTACT INFORMATION

Division Questions about: Phone number

Accounting Division

Vesting, contributions, service credit, deductions and Social Security coverage

217-785-7191

Purchasing service credit (by last 2 of SSN)

(34-67) 217-557-2058

(68-99) 217-557-9946

(00-33) 217-785-7187

Administrative Services Division

SERS brochures, handbooks and beneficiary forms

217-785-7444

Claims Division Fax: 217-524-2293

Death claims 217-785-7366

Disability claims 217-785-7318

Benefit Support 217-785-7150

Eligibility and calculations for a pension benefit

217-785-7343

Address changes, direct deposits, repayment of widow/survivor funds and payment vouchering

217-785-7034

Refunds

217-785-7164

Refunds fax: 217-785-6964

Field Services Division Fax: 217-557-5154

Retirement coordinator designations, pre and post retirement seminars, individual counseling and benefit seminars

Chicago office:312-814-5853

Springfield office:217-785-6979

ADDITIONAL RESOURCESRetirement coordinator website

srs.illinois.gov/RC/RCgeneral_sers.htm

Employer websitememberservices.srs.illinois.gov

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Designating an agency head or administratorEach agency must file a SERS Online Security Form with the Field Services Division at SRS. The SERS Online Security Form designates the agency head or administrator who approves retirement coordinators. Online access is denied for all employers until this form is filed with SRS.

Designating a retirement coordinatorAll retirement coordinators (RCs) will need to complete the Agency Retirement coordinator Appointment Request Form and have their agency’s designated agency head or administrator submit the form. This process serves two purposes: to create a role for the person as a new RC with assigned pay codes, as well as to provide the employee with access to the Employer Website. Before completing the form, retirement coordinators will need to have an Illinois Public ID.

Designating a payroll coordinator and/or signature designeeRetirement coordinators are responsible for signing up and approving their agency’s payroll coordinators and signature designees. All payroll coordinators and signature designees need to complete the Agency Payroll Coordinator and Signature Designee Appointment Request Form and have the retirement coordinator submit the form in order to gain access to the website. Before completing the form, payroll coordinators and signature designees will need to have an Illinois Public ID.

FormsAll three forms are available on the Security page of the Employer Website. Only the retirement coordinator will have access to the Security page. Payroll coordinator or signature designees are not be able to access the security page or view the Security menu item. It is the retirement coordinator’s responsibility to complete the necessary security forms to change an agency head/administrator or add a new retirement coordinator, payroll coordinator or signature designee.

Illinois Public ID accounts are free and secure accounts created by CMS. If you have trouble creating your Illinois Public ID account, you can contact our technical support by calling the SRS Help Desk at (217) 782-4202 or contact them via email.

DESIGNATING AN AGENCY RETIREMENT COORDINATOR

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TiersTier 1 employees hired 1/1/1984-12/1/2010 serve a qualifying period. After that, they automatically become a member of the State Employees’ Retirement System, which means they begin having required contributions deducted from their pay and credited to their account. If an employee was hired prior to 1984, see chart below.

Tier 2 employees are automatic members who do not serve a qualifying period and begin making contributions immediately.

The qualifying period chart below illustrates the period based on hire date:

If hired:Qualifying period:

Prior to Jan. 1, 1972 12 months

Between Jan. 1, 1972 - Dec. 31, 1983 0 months

Between Jan. 1, 1984 - Nov. 30, 2010 6 months

Retirement formulasRegular formula: The retirement formula for state employees in positions not designated as high-risk.

Alternative formula: The retirement formula for state employees in certain high-risk jobs.

Coordinated vs. noncoordinatedCoordinated members: Anyone entering state employment after Jan. 1, 1969 is required to contribute to both SERS and Social Security.

Noncoordinated members: In October 1968, eligible members had the option of contributing only to SERS and opting out of Social Security contributions. Members who chose this could not choose to become coordinated at a later date.

ContributionsState law requires SERS members to contribute a percentage of their salary to SERS.

Regular formula contributions are as follows:

PensionSurvivors’

benefitTotal

Coordinated members (contribute to Social Security)

3.5% + 0.5% = 4.0%

Noncoordinated members (do not contribute to Social Security)

7.0% + 1.0% = 8.0%

Alternative formula contributions are as follows:

PensionSurvivors’

benefitTotal

Coordinated members (contribute to Social Security)

8.0% + 0.5% = 8.5%

Noncoordinated members (do not contribute to Social Security)

11.5% + 1.0% = 12.5%

Employees who are members of a collective bargaining agreement may have their contributions “picked-up,” or in other words, paid by the State of Illinois.

Some state agencies provide a pick-up amount that is less than the required employee contribution. In those agencies, the employee would pay the remaining balance. The employee pick-up amounts range from 1% to 5.5%. SERS credits all contributions to the member’s account, regardless of who makes the contribution.

SERS MEMBERSHIP

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Member identificationIn the past, SERS has used Social Security numbers as member identification, but we are transitioning to using Member IDs. When corresponding with SERS’ employees, always provide the member’s name, address and last four digits of the Social Security number or Member ID.

Membership recordTier 1: SERS mails each member a membership record, which must be completed and returned to us.

Tier 2: All employees hired after Dec. 31, 2010 automatically become SERS members and SERS mails them a membership record when they begin employment.

Members can request duplicate membership records through our Springfield office.

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Retirement Coordinator Responsibilities

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Each state agency will designate a retirement coordinator to serve as a representative between SERS and the agency. The retirement coordinator is responsible for the proper enrollment of members, including completion of the various forms necessary for the operation of SERS, as directed by this retirement coordinator’s manual. Any information provided by a retirement coordinator will not supersede or modify the statutes or rules and regulations governing SERS.

Preparation & identification of documentsThe retirement coordinator should help the employee fill out all necessary member record and benefit paperwork, encouraging the employee to keep a copy of all documents for his or her files. All correspondence should have the employee’s name and SERS ID/last four of SSN as well as the employer’s name.

Distributing retirement plan materialsRetirement coordinators are responsible for providing each participating SERS member with the most current plan materials, including handbooks, brochures and all other official notices from SERS.

False statements“...knowingly making a false statement or falsifying a record in an attempt to defraud SERS is a class 3 felony...”

(40 ILCS 5 § 14-148. Source: P.A. 80-841.)

Confidential informationSERS files are confidential, and we do not release files to anyone but the member unless that member sends a written Authorization to Release Form.

RETIREMENT COORDINATOR RESPONSIBILITIES

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Member Responsibilities3

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Appeals and hearings before the Board of TrusteesAny member, annuitant or beneficiary adversely affected by the initial disposition of a claim by the System’s staff may have the claim reconsidered at a hearing before the Executive Committee or by filing a written appeal with the Executive Committee.

The hearing and written appeal procedures can be found in the Administrative Rules at section 1540.270.

Hearings will be conducted before the Executive Committee by the Hearing Officer and will be of an informal nature. The Hearing Officer will conduct a full and fair hearing, receiving testimony from the claimant, admitting exhibits into evidence, avoiding delay, maintaining order and making a sufficient record for a full and true disclosure of the facts and issues. The Hearing Officer will make all procedural and evidentiary rulings necessary for the conduct of the hearing.

All Petitions for written appeal should be directed to the Executive Secretary of the System at the Springfield Office within 30 days following the notification of the initial disposition of the claim.

A petition for a written appeal should have the name and address of the petitioner, the name and address of his or her authorized representative (if applicable), a brief statement of the facts forming the basis of the written appeal, including any new or additional evidence, and the relief sought.

The Executive Committee will consider written appeals at the next regular meeting of the Executive Committee more than 15 days after the receipt of the Petition.

The written recommendation of the Executive Committee will be mailed to the petitioner (and authorized representative, if applicable), and the appropriate action will be implemented by the Executive Committee if approved by the Board of Trustees.

Forfeit of benefitsHonorable service is a condition of both employment and the receipt of any employment related benefits. Title 40 of the Illinois Compiled Statutes, Section 14-149 provides no benefits will be paid to any person who is convicted of any felony relating to or arising out of or in connection with his service as an employee.

Name and address changesAll active members must submit their name and address changes through their employing agency by filling out two W-4 cards (one for their agency file and one for the agency payroll department to forward to the Comptroller’s office) and providing supporting documentation.

Retired and inactive members can submit name and address changes via the Member Change of Address/Member Information Form (Form 501), or in writing (may be electronic) with documentation.

Beneficiary changesThe designation of a beneficiary is important because it allows SERS to pay a member’s accumulated contributions plus interest or a death benefit to a person chosen by the member.

Retirement coordinators should encourage members to keep their beneficiary designations current, and provide Form 101 (Member’s Nomination of Beneficiary(ies) for Death Benefits) to members.

CorrespondenceIn all correspondence with SERS, members are encouraged to provide their full name, SERS ID number or the last four digits of their SSN, their agency, a current mailing address and their signature.

MEMBER RESPONSIBILITIES

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Qualified Illinois Domestic Relations Orders (QILDRO)QILDROs are legal orders put into place when retirement benefits are being divided. These often occur during a divorce proceeding, which entitles the alternate payee (typically a former spouse, child or other dependent) to all or a portion of the retirement benefit owed to the member.

A QILDRO Calculation Order is an accompanying document to be used when a QILDRO calls for division of benefits on a percentage basis.

Survivor, disability or health insurance benefits are not affected by a QILDRO. However, monthly retirement benefits, refunds and death benefits are affected by a QILDRO.

SERS will only provide the member’s benefit information to an attorney in response to a subpoena as long as the member is vested. The member can request their benefit information via phone or written authorization to release the information.

We will provide the benefit information, accurate as of the date provided, within 45 days of receiving the request of subpoena and a $50 processing fee. There is an additional $50 fee for filing the QILDRO, as well as a $50 fee for filing the Calculation Order.

We do not provide actuarial opinions about the present market value of a member’s benefits or other interests, nor do we assume future events, such as additional service credit or future salary increases. We do not provide benefit information for marital periods or specific years.

Rollovers into the SERS defined benefit planA member may request SERS to accept a transfer/rollover from an eligible plan or individual retirement account (IRA) and deposit it in the defined benefit plan for the purpose of repaying a refund or to purchase eligible service credit. SERS will provide the appropriate form upon request.

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Service Credit4

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Service credit is the total amount of credit toward a member’s retirement, including member and/or employer contributions, any optional credit that may have been purchased, free military service available, or other various qualified credits (such as disability or unpaid sick time). A member may earn a maximum of one service credit per month.

Members must establish all service credit prior to retirement.

How do you get it?Service credit is earned through each month the member (or employer, on the member’s behalf) makes the required contributions.

The amount of credited service affects the amount of retirement benefit available to the annuitant; the more months of service, the greater the benefit.

How service credit is calculated

Monthly & daily

employees

Hourly employees

Monthly credit

15 or more days 75 or more hours 18-14 days 38-74.9 hours 1/2

less than 8 daysless than 38

hours1/4

Optional service creditThis is time that can be purchased by a member to increase a pension or allow earlier retirement.

Optional service credit includes: •Leave(s)of absence •Paidmilitaryservice •Qualifyingperiod •Repaymentof arefund •Shortperiod

All optional service credit must be paid and established before retirement.

Purchasing service credit for periods when members did not contributeMembers may purchase service credit from periods of employment where they did not contribute by making a retroactive payment with interest, either in a lump sum or installments.

Members who are purchasing military service and/or repaying a refund may purchase part of their service credit or it may be purchased as a whole. Note: military time must be purchased in whole month increments.

Qualifying periodQualifying periods only apply to Tier 1 members, and they are periods that a member must serve before their contributions begin. Once members have served their qualifying period, the option to buy their service credit for that time, with interest, is their option until they retire.

The qualifying period chart below illustrates the period based on hire date:

If hired:Qualifying period:

Prior to Jan. 1, 1972 12 monthsBetween Jan. 1, 1972 - Dec. 31, 1983 0 monthsBetween Jan. 1, 1984 - Nov. 30, 2010 6 months

Short periodA short period is an intermittent time of employment, not exceeding the length of a qualifying period.

Leave(s) of absenceMembers may establish service credit for an authorized leave of absence of less than one year if the leave began on or after Jan. 1, 1982.

A member may also establish service credit for more than one leave of absence. The total period of service established can exceed one year when combining multiple leaves.

Members are required to pay employee and employer contributions, plus interest, when purchasing service

SERVICE CREDIT

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credit for a leave of absence. For members under Central Management Services (CMS), SERS will verify the leave of absence by reviewing CMS records. For members not under CMS jurisdiction, Form #2067 – Certification of Leave of Absence verifies a leave of absence.

Military serviceMembers who served as active duty in the United States Army, Navy, Air Force, marines, Coast Guard or any of the women’s auxiliaries may purchase up to a maximum of 48 months of service credit for their military time. Military time may be purchased in month increments. It must be purchased while employed.

SERS grants two types of military service credit:

1. Free credit with no contributions - when ALL of the following conditions are met:

•Memberwasastateemployeewithinsixmonthsimmediately before entering military service

•Memberreturnedtostateemploymentwithin15months after honorable discharge

•Memberestablishescreditablestateserviceimmediately before and after military service

2. Paid credit with contributions Members who don’t qualify for free military service credit may purchase up to four years of military credit by paying the required employee/employer contributions and interest, provided:

•Memberwasnotdishonorablydischarged •Theservicecreditpurchaseddoesnotexceed

five years when added to any free military service granted

SERS calculates interest from the date the employee last became a member of SERS, or Nov. 19, 1991, whichever is later.

Before SERS grants any military credit or determines cost, we must receive a copy of Form DD-214 or the appropriate separation or discharge papers verifying active duty.

Members can make payments in a lump sum, direct payment or installments. Members may pay installments by payroll deduction on a pre or post-tax basis.

Members have up to five years to pay contributions and interest. SERS does not approve direct payments for less than $20 per pay period. SERS does not approved payroll deductions for less than $10 per pay period.

Members may also transfer money from their deferred compensation account to purchase service credit and/or repay a refund if there is enough money in the member’s account to pay the full amount owed to SERS.

Active Duty Call Ups Members called to active military duty typically remain on the state payroll and receive the difference between their full state salary and the federal military pay.

Employee retirement contributions are due on the differential pay. SERS will submit a billing statement to the employee for the appropriate amount of contributions due on these wages.

There is no interest charged on the contributions, but the employee is required to pay the amount due, as this is not an optional service purchase.

Members may pay for these contributions using a Time Payment Agreement (TPA) on a pre or post-tax basis. Members can write personal checks for post-tax purchases, and make pre-tax transfers from their deferred compensation account.

Purchasing service credit for periods when members’ contributions were refundedWhen a member leaves state employment, if they chose to take a refund of contributions and were then later rehired, they may choose to repurchase the refund with interest.

The member must establish 24 months of service credit before they are eligible to repurchase their refund. They may use reciprocal time to establish this service credit.

Members may repay contribution refunds in one month or multiple-month increments at a time, but each repayment agreement must be repaid in full before any other contribution refunds may be repurchased and/or before retirement.

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Miscellaneous service credit purchases •LegislativeStaff InternshipProgram •Membercanpurchaseuptooneyearof service

credit by paying employee contributions and interest

•Governorappointee •Membercanpurchaseservicecreditbypaying

employee contributions and interest •GovernmentPublicServiceIntern(GPSI) •Membercanpurchaseuptotwoyearsof

service credit by paying employee and employer contributions and interest

Payment methods for purchasing service creditThere are various ways a member can purchase service credit.

CheckMember will need to include a copy of the letter they received showing the amount due.

Rollover from an IRAMembers must complete a Rollover Certification Form (2064), which they will need to request from SERS.

Rollover from deferred compensationMember must contact CMS Deferred Compensation. Transfer is done on approx. the 20th of each month (depending on holidays and weekends).

Installment •Directpay(aftertax) •Payrolldeduction

If the installment plan exceeds two years, an interest rebate will be refunded to the member.

If the member leaves state service or retires before final due date, the balance will be calculated and due immediately. If the member chooses not to pay the balance, the previous payments will be refunded and the service credit will not be reinstated to the member’s account.

Lump-sum from sick and vacation timeMembers can only opt for this option at the time of retirement.

SERS informs employees of the eligible credit and the required payment. There is a five-year time limit to pay contributions and interest. SERS does not approve direct payments for less than $20 per pay period. SERS does not approved payroll deductions for less than $10 per pay period.

Once the member has paid for their service purchase in full, an acknowledgement will be mailed showing the months posted to the member’s account.

Sick, vacation and personal timeUnused and unpaid sick, vacation and personal time can be used to meet service eligibility requirements and increase a member’s retirement benefit. The additional service credit does not affect final average compensation.

Members can make the contributions on a pre- or post-tax basis. Members may use their lump-sum payment for vacation and/or sick pay to purchase additional service credit. To be eligible for this option, the member’s retirement date must be effective within 90 days of resignation and they need to sign a Form 1404 with their agency.

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Vacation leaveAll permanent, salaried employees earn vacation leave based on their total state employment.

•Upto5yearsof service:10days

•5-9yearsof service:15days




•25yearsof service:25days

Sick Leave & Vacation Service Credit Conversion Chart

Days = Months Days = Months1-5 = ¼ 131-135 = 6¼

6-10 = ½ 136-140 = 6½11-21 = 1 141-151 = 722-26 = 1¼ 152-156 = 7¼27-32 = 1½ 157-161 = 7½33-43 = 2 162-173 = 844-48 = 2¼ 174-178 = 8¼49-53 = 2½ 179-183 = 8½54-65 = 3 184-195 = 966-70 = 3¼ 196-200 = 9¼71-75 = 3½ 201-205 = 9½76-86 = 4 206-216 = 1087-91 = 4¼ 217-221 = 10¼92-96 = 4½ 222-226 = 10½

97-108 = 5 227-238 = 11109-113 = 5¼ 239-243 = 11¼114-118 = 5½ 244-248 = 11½119-130 = 6 249-260 = 12

ReciprocityIf a member participated and contributed at least one year of non-concurrent service with an Illinois Public Retirement System under the Reciprocal Act, their service under that system could be used to determine eligibility for their SERS benefit.

The amount of the benefit is based on the benefit formula and service credit in each system, and the member will receive a payment from each system. The annual increases are made according to the rules of each separate system’s statutes.

Under the Reciprocal Act, the highest final average within the last 120 months is used for calculating the benefits for all systems, however total benefits cannot be higher than they would have been if all service would have been in one system.

Reciprocal systems:• Chicago Teachers’ Pension Fund

• County Employees’ Annuity & Benefit Fund of Cook County

• Forest Preserve District Employees’ Annuity & Benefit Fund of Cook County

• General Assembly Retirement System

• Illinois Municipal Retirement Fund

• Judges’ Retirement System

• Laborers’ Annuity & Benefit Fund of Chicago

• Metropolitan Water Reclamation District Retirement Fund

• Municipal Employees’ Annuity & Benefit Fund of Chicago

• Park Employees’ Annuity & Benefit Fund of Chicago

• State Employees’ Retirement System of Illinois

• Teachers’ Retirement System

• State Universities Retirement System

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Refunds5

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If a member leaves state service, they can choose to take a refund of their contributions. Once they’ve been off payroll for 14 days the member is eligible to request their refund.

Members who want a refund should contact the Claims Support Division at 217-785-7164 to receive a refund packet. This includes Form #2000 – Request for Refund of Member’s Retirement Contributions and tax information. SERS sends the Retirement Coordinator a certification to complete.

SERS cannot process the refund until we receive both the member’s application and the agency certification. Agencies are required to complete all sections of the agency certification; leaving any blanks will cause delays in processing by SERS.

Members who have eight or more years of state service, one or more years under the Reciprocal Act or members who expect to return to state service, may consider leaving their contributions in SERS for future retirement or survivor benefits.

The statutes governing SERS state members convicted of a felony related to their employment with the State of Illinois are ineligible for any payable benefit from SERS.

RCs should notify the SERS Pensions supervisor when an employee terminates for a criminal act connected with his or her employment.

Inactive account refundsInactive members who choose to take a refund will be required to provide two forms of identification, which can include: •Photocopyof validdriver’slicenseorID •Birthcertificate •Passport •Marriagelicense •Firearmowner’sID •Baptismalrecord

Cancelling a refund requestIf a member wants to cancel a refund request, an immediate written notification is needed. If the member wants to cancel the request after receiving the refund, they may return the non-cashed check to our office.

If the check has been cashed, the refund cannot be cancelled.

Final reserve transfer (write-off)When there is an account for seven years without a valid address, the account balance will be transferred to the employer reserve. These accounts will be reviewed each year prior to their transfer by the manager of the Refunds and Accounting divisions.

The account may be reinstated with a written inquiry from the member including: •Completedapplication •Photocopyof atleasttwoof thesameformsof

identification* as the inactive account refunds •*Anytransferredaccountswillrequireoneof the

IDs to be a copy of the Social Security card

REFUND OF CONTRIBUTIONS

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Repayment of refundsIf a member terminates state employment, receives a refund of contributions and the member is later rehired, they may reestablish their service credit by repaying the refund with interest after completing at least two years of service with SERS, or any of the other Reciprocal Illinois Public Retirement Systems. Members must repay contributions and interest before retirement to reestablish service.

To reestablish service credit:

1. Members must provide all information before we can process the request. SERS will inform the member of the eligible credit and the amount of required payment.

2. Submit Form #2071 – Irrevocable Payroll Authorization of Permissive Service Credits if the member wants to pay by tax-deferred payroll deduction.

SERS informs employees of the eligible credit and the required payment. There is a five-year time limit to pay contributions and interest. SERS does not approve direct payments for less than $20 per pay period. SERS does not approved payroll deductions for less than $10 per pay period.

Once the member has paid for their service purchase in full, an acknowledgement will be mailed showing the months posted to the member’s account.

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Disability BenefitClaims

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Claim notificationThe Claim Notification Form #3901 is used for benefit claims. In all cases, the member should list their name, address, Social Security number and agency.

RCs should complete the agency section of the form and send it to the Claims Division. When we receive the notification, we send the application forms directly to the member.

Nonoccupational Disability: Send us the Claim Notification Form once you know the member will not have enough sick days to cover their time off. For the date of disability, indicate the date the member became disabled.

For the date the leave of absence begins, indicate the date the member was removed from payroll. Write the date the member will return to work in the comment section. Specify if the disability is for maternity.

Occupational Disability: Send us the Claim Notification Form after the member has applied for Workers’ Compensation benefits. Indicate what date the member was injured and list the date the member was removed from the payroll.

Death: List the name and address of dependents, including phone numbers, if possible.

Birth certificateA copy of the member’s birth certificate is required for processing all claims. If SERS does not have one on file, we cannot pay benefits until we receive a copy of the member’s birth certificate.

SERS will send the member Form #3928 – Request for Birth Certificate if we do not have their birth certificate on file.

There are three types of disability benefits available to SERS members:

Nonoccupational Disability: If a member becomes ill or injured from causes not work-related, they may be eligible to receive this benefit.

Occupational Disability: Members receive a benefit if they are unable to work due to a work-related illness or injury.

Temporary Disability: This benefit is payable in disputed Workers’ Compensation cases when the member’s agency has denied all benefits or Workers Compensation benefits have been terminated, and an appeal has been filed with the Illinois Industrial Commission.

Service credit continues to build while an employee is receiving disability benefits. Insurance coverage is the same for those on disability as those working.

Nonoccupational disability benefitsTo be eligible for a nonoccupational disability benefit, the member must meet the following conditions:

•Haveaminimumof 18monthsservicecreditwithSERS or a reciprocal retirement system.

•Usedallaccumulatedsickleave. •Grantedamedicalleaveof absence. •Filedamedicalreportfromalicensedmedical

doctor to SERS. •SenttherequiredformstoSERSwithin90daysof

being removed from the payroll. •SERSdeterminesthatthememberisdisabled.

Benefits begin to accrue on the latest of: •The31stdayof absencefromworkbecauseof

disability (including periods when member received sick pay).

•Thelastdaytheemployeereceivedcompensation(including periods when member received sick pay).

•Thedatewereceivetheapplication,if theapplication is delayed more than 90 days after removal from the payroll.

DISABILITY BENEFIT CLAIMS

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The nonoccupational disability benefit equals 50% of final average compensation on the date the employee is removed from the payroll. If the employee pays into Social Security, the SERS benefit is reduced by the amount payable from Social Security.

If a nonoccupational disability continues for five full months, the member’s insurance transfers from the agency to SERS.

Check with the SERS Insurance Section before terminating the insurance of anyone on a leave of absence. Follow the instructions in the monthly Disability Benefit Recipients list sent to your agency, and forward the latest original CMS Group Insurance Turnaround/Change form and CMS-617 (beneficiary designation) to SERS.

Tier 1 & 2 employees are entitled to the following nonoccupational benefits: •One-half of theirservicecredit,uptoage65if the

disability began prior to age 60. If the disability began after age 60, benefits are payable for a maximum of five years.

•One-half of theirservicecreditif thedisabilityoccurred after age 60, or five years from the date benefits began, whichever occurs first.

Benefits end when: •Thedisabilityceases. •Theemployeeexhaustsone-half of theirservice

credit. •TheemployeereturnstoStateemployment.

Applying for nonoccupational disability benefitsThe RC must complete these forms:When a member requests a disability leave of absence, complete and forward Claim Notification Form #3901 to SERS.

Once we receive notification, we send a disability packet to the member to complete and send a Statement of Employer Form #3900 and a Job Duty Statement Form #3935 to you.

The member’s supervisor needs to complete Form #3900 and #3935 and then send back to us.

The member (unless otherwise noted) must complete these forms/documents and send to SERS as soon as possible: •Member’sApplicationforDisabilityBenefits

Form #3924•Member’sAuthorizationForm#3934•*DisabilityMedicalReport#3114

The member’s physician must complete this.•Birthcertificate• For those over 65, the Unreduced Social Security

Pension Estimate Form #3129 is required.

Occupational disability benefitsTo be eligible for occupational disability benefits the member must: •FileaclaimwiththeIllinoisWorkers’Compensation

Commission (WCC), the Risk Management Division of their agency, or the Department of Central Management Services to determine if the disability is work-related.

•FiletherequiredformswiththeSERSClaimsDivision within 12 months of:

•Removalfrompayroll. •BecomingeligibleforbenefitsunderWorkers’

Compensation. •TheIllinoisWCCapprovingtheWorkers’

Compensation benefit. •HaveSERSdeterminethemdisabledfrom

performing their assigned job duties.

Benefit AmountThe amount of the disability benefit is 75% of final average compensation at the time of the disability, minus any benefit received from Workers’ Compensation.

For both Tiers 1 & 2, if the disability occurred before age 60, benefits are payable up to age 65. If the disability occurred after age 60, benefits are payable for five years. Disability benefits cease when the member earns one-half of their earned service credit, or returns to State employment.

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Applying for Benefits •CompleteandforwardtheClaimNotificationForm

#3901 and the Statement of Employer Form #3900 when the member requests Workers’ Compensation benefits.

•TheJobDutyStatementForm#3935mustbecompleted by the member’s supervisor when the member applies for disability and should be sent with the Statement of Employer form.

•Acopyof theinjuryreportmustalso be included.

•SERSwillcontactyouragencyregardingaGroupInsurance transfer once the member has received a final award from the Illinois Industrial Commission.

The member (unless otherwise noted) must complete these forms/documents and send to SERS as soon as possible: •Member’sApplicationforOccupationalDisability

Benefits Form #3213 •Member’sAuthorizationForm#3934 •Birthcertificate •*TheDisabilityMedicalReportForm#3213

The member’s physician must complete this.

Temporary disabilityThis benefit is available in disputed Workers’ Compensation cases when the agency responsible for determining the liability has formally denied all benefits, and an appeal is pending with the Illinois WCC, or when Worker’s Compensation have terminated benefits and the member has requested an emergency hearing with the Illinois WCC.

A member may be eligible for a temporary disability benefits if: •SERSdeterminesthatthememberisdisabled. •Theyhaveatleast18monthsof creditedservice

with SERS or a reciprocal retirement system. •Theyfiledanapplicationwithin12monthsof the

date a disability, resulting in a loss of pay. •TheyfiledanappealwiththeIllinoisWorkers’

Compensation Case. •TheysubmittedtherequiredformstoSERS.

•Theyhavenotreceived,orhadarighttoreceive,any compensation for at least 30 days.

If a member is eligible, SERS will retroactively pay temporary disability benefits from the 31st day after removal from payroll.

If Workers’ Compensation terminates benefits, a member may be eligible for temporary disability benefits if: •SERSdeterminesthatthememberisdisabled. •Theyhaveatleast18monthsof creditedservice

with SERS or a reciprocal retirement system. •Theyhavesubmittedtherequiredforms

to SERS. •TheyhavefiledanappealwiththeIllinoisWCCand

requested an emergency hearing. •Theyhaveserveda150-daywaitingperiod.

Applying for temporary disability benefitsSend temporary disability requests on Claim Notification Form #3901, and indicate the situation in the Comment Section.

The member (unless otherwise noted) must complete these forms/documents and send to SERS as soon as possible: •Member’sApplicationforTemporaryDisabilityBenefits

Form #3924•Member’sAuthorizationForm#3934•*DisabilityMedicalReport#3114

The member’s physician must complete this.•Birthcertificate• For those over 65, the Unreduced Social Security

Pension Estimate Form #3129 is required.•Copyof ApplicationforAdjustmentof Claim

Form sent to Illinois Industrial Commission•Copyof Workers’Compensationdenial

If a member is applying for temporary disability benefits due to Workers’ Compensation terminating benefits, a copy of the Workers’ Compensation termination letter and a copy of the 19(b)1 form is needed when filing with the Illinois WCC.

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Retirement Pension Eligibility

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Retirement under regular formulaRegular Formula applies to the majority of SERS members. Under our Regular Formula, an annuitant is limited to a maximum retirement benefit of 75% of their final average compensation. To achieve the 75% maximum, a Regular Formula employee would need 44 years and 11 months of service credit total.

Coordinated members (contributing to Social Security) will receive 1.67% of their final average compensation for each year of service.

Non-coordinated members (not contributing to Social Security) will receive 2.2% of their final average compensation for each year of service.

Tier 1Vesting eligibility: •Age60with8yearsof servicecredit;or •Ruleof 85;or •35yearsof servicecreditatanyage;or •Earlyretirementwithreducedbenefits

AmountThe amount is calculated by taking the member’s highest final average compensation for 48 consecutive months out of the last 120 months.

Reduced Retirement BenefitA Regular Formula member can retire between the ages of 55-60 with 25-30 years of service credit with a reduced pension of 1/2 of 1% for each month under age 60.

Benefit Cost of Living (COLA) increases*If a member retires at age 60 or older, they will receive a 3% pension increase Jan. 1 each year following their first full year of retirement. If a member retires under the Rule of 85, they are eligible for their first 3% increase on Jan. 1 following their first full year of retirement, even if they are not age 60.

If a member retires before age 60 with a reduced retirement benefit, they will begin receiving a 3% pension increase Jan. 1 each year after they turn age 60 and have been retired at least one full year.

Tier 2 Vesting eligibility: •Age67with10yearsof servicecredit •Earlyretirementwithreducedbenefits Members who are between the ages of 62-67 with

10 years of service credit may retire at a reduced benefit. The pension will be reduced by ½ of 1% for each month prior to age 67.

AmountThe amount is calculated by taking the member’s highest final average compensation for the highest 96 consecutive months out of the last 120 months, and the benefit is based on an annual maximum salary limit, which is subject to change.

Reduced Retirement BenefitA Regular Formula member can retire between the ages of 62-67 with 10 years of service credit with a reduced pension of 1/2 of 1% for each month under age 67.

Benefit Cost of Living (COLA) increases*If a member retires at age 67 or older, they will receive a pension increase of 3% or one-half of the Consumer Price Index for the preceding calendar year, whichever is less, on Jan. 1 each year following their first full year of retirement.

If a member retires before age 67 with a reduced retirement benefit, they will begin receiving a pension increase of 3% or one-half of the Consumer Price Index for the preceding calendar year, whichever is less, Jan. 1 each year after they turn age of 67 and after being retired at least one full year.

* Pension increases are not limited by the 75% maximum.

RETIREMENT PENSION ELIGIBILITY

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Retirement under alternative formulaAlternative Formula was designed for certain high-risk jobs. Under our Alternative Formula, an annuitant is limited to a maximum retirement benefit of 80%. To achieve the 80% maximum, an Alternative Formula employee would need 32 years of service credit total.

Coordinated employees (contributing to Social Security) will receive 2.5% of their final average compensation.

Non-coordinated employees (not contributing to Social Security) will receive 3.0% of their final average compensation.

Tier 1Vesting eligibility: •Age50with25yearsof servicecredit;or •Age55with20yearsof servicecredit.

AmountThe amount is calculated by taking the member’s highest final average compensation as follows.

If the member is alternative formula prior to 1/1/98: •Theaverageof thehighest48consecutivemonths

out of the last 120 months (for members in service prior to Jan. 1, 1998); or

•Theaverageof thelast48monthsof service;or •Finalrateof pay(cannotexceedtheaverage

of the last 24 months of pay by 115%).

If the member is alternative formula after 1/1/98: •Theaverageof thelast48monthsof service;or •Finalrateof pay(cannotexceedtheaverage

of the last 24 months of pay by 115%).

Benefit Cost of Living (COLA) increases*If a member retires at age 55 or older, they will receive a 3% pension increase Jan. 1 each year following their first full year of retirement.

Tier 2Vesting eligibility: •Age60with20yearsof servicecredit

AmountThe amount is calculated by taking the member’s highest final average compensation for 96 consecutive months out of the last 120 months.

The retirement benefit is calculated on an annual maximum salary limit, which is subject to change.

Benefit Cost of Living (COLA) increases*If a member retires at age 60 or older, you will receive a pension increase of 3% or one-half of the Consumer Price Index for the preceding calendar year, whichever is less, Jan. 1 each year following their first full year of retirement.

* These pension increases are not limited by the 80% maximum.

• Air Pilots• Arson Investigators• Attorney General Investigators• Central Management

Services Police• Commerce Commission

Police Officers • Conservation Police• Controlled Substance Inspectors• Dangerous Drug Investigators• Department of Corrections’ Security

Employees (includes Prisoner

Review Board)• Department of Human Services Security

Employees• Firefighters• Revenue Investigators• Secretary of State Investigators• Special Agents• State Highway Maintenance Workers• State Police• State Police Investigators• State’s Attorneys Appellate Prosecutor

Investigators

Tier 1 positions eligible for alternative formula:

• Firefighter• Security Employee with the Department of

Corrections or Juvenile Justice (includes the Prisoner Review Board)

• State Policeman

Tier 2 positions eligible for alternative formula:

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Pension: Send us the completed retirement packet approximately 30 days before the member’s effective date of retirement. Indicate the first day of the month following the member’s removal from payroll.

If the member has funds in a reciprocal system, list the system in the comment section. Have the employee contact the other reciprocal system directly to apply for a pension. Indicate whether the member is married, has dependent children, etc.

Pension Estimate: List the separation date/planned retirement date and the date the member will be removed from payroll. For the effective date of retirement, indicate the first day of the month the member would be eligible for a pension. List the number of unused sick and vacation days.

If the member has funds in a reciprocal system and requests an estimate from these system(s), display the reciprocal systems in the comment section.

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Death BenefitClaims

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Nonoccupational death benefits(Throughout this section, spouse & civil union partner are interchangeable.)

If a member contributed to SERS and Social Security, a benefit offset could be applied to the widow or survivor benefit when the survivor becomes eligible for Social Security benefits.

Any member who retires after July 1, 2009 will have the option at the time of retirement to remove the offset provision. In exchange for the removal, SERS will reduce the member’s retirement annuity by 3.825% monthly.

If a member dies while actively employed and has at least 18 months of service, their qualified survivors will be eligible for benefits.

SERS will also pay the member’s pension contributions to the named beneficiary(ies).

If a member dies with no qualified survivors while actively employed, the named beneficiary(ies) will receive all contributions, plus interest, and one month’s salary for each year of service, up to a maximum of six months’ salary.

Survivor benefitsSpouse: If a member is survived by a spouse age 50 or over,

and they were married at least one year prior to death, (s)he will receive $1,000, plus a monthly annuity up to a maximum of $400, or 50% of the earned pension if it provides a greater monthly benefit, until death.

TIER 2: If 66 2/3% of your earned pension provides a greater monthly benefit than the amounts stated above, it is payable to your spouse.

Spouse and Children: If the spouse supports children under age 18 (22 if

full-time student), or a disabled child over 18, (s)he can receive benefits before age 50. (S)he will receive $1,000, plus a monthly annuity up to a maximum of $600.

This benefit is payable until the last child reaches age 18 (22 if full-time student), marries, dies or is no longer disabled. If 50% of the earned pension provides a greater monthly benefit than the amounts stated above, it is payable to the family.

TIER 2: If 66 2/3% of your earned pension provides a greater monthly benefit than the amounts stated above, it is payable to your family.

Children: If a member is not survived by a spouse, but has

children under age 18 (22 if full-time student), or over 18 and disabled, they can receive $1,000 plus a monthly annuity up to a maximum of $600.

This benefit is payable until the last child reaches age 18 (22 if full-time student), marries, dies or is no longer disabled. If 50% of the earned pension provides a greater monthly benefit than the amounts stated above, it is payable to the children.

TIER 2: If 66 2/3% of your earned pension provides a greater monthly benefit than the amounts stated above, it is payable to your children.

Dependent Parents: If no spouse or children survive the member, the

dependent parents may be eligible for benefits.

DEATH BENEFIT CLAIMS

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Death after retirementIf a member dies after retiring, survivor benefits are subject to the same maximums as those payable during active employment, or 80% of the pension the member received before dying, whichever is less.

If 50% of the pension provides a greater monthly benefit than the amounts stated above, it is payable to the member’s survivors.

TIER 2: If 66 2/3% of your earned pension provides a greater monthly benefit than the amounts stated above, it is payable to your survivors.

If the member has no survivors, the beneficiary(ies) will receive any remaining contributions and interest, or $500, whichever is greater.

Death after terminationIf death occurs after termination of state employment but before retirement benefits begin, the member must have eight years of service to qualify for survivor benefits.

The survivor benefits are subject to the same maximums as those payable during active employment, or 80% of the eligible pension amount before they died, whichever is less.

TIER 2: If 66 2/3% of your earned pension provides a greater monthly benefit than the amounts stated above, it is payable to your survivors.

If the member dies after termination with no survivors, or with less than eight years of service, the named beneficiary(ies) will receive all contributions and interest.

Occupational death benefitsIf a member dies from a work-related injury or illness, as determined by the Illinois WCC, their survivors are eligible for an occupational death benefit. SERS reduces the benefit amount by any payments awarded under the Workers’ Compensation Act, or the Workers’ Occupational Diseases Act.

If the member has no qualified survivors, the nominated beneficiary(ies) will receive all contributions, plus interest, and one month’s salary for each year of service, up to a maximum of six months’ salary. The occupational death benefit is increased 3% each January 1, following the first anniversary of the annuity.

Occupational survivor benefitsSpouse: If a member is survived by a spouse, (s)he will receive a

monthly annuity equal to 50% of the member’s salary until the spouse’s death.

Spouse and Children: If the spouse supports children under age 18 (22 if

full-time student), or a disabled child over age 18, they can receive benefits up to a maximum of 75% of the member’s salary. This benefit is payable until the spouse dies, remarries before age 55 or the last child reaches age 18 (22 if full-time student), marries, dies or is no longer disabled.

Children: If a member is not survived by a spouse, but has

children under age 18 (22 if full-time student), or over age 18 and disabled, they can receive a monthly annuity, up to 50% of your salary. This benefit is payable until the last child reaches age 18 (22 if full-time student), marries, dies or is no longer disabled.

Dependent Parents: If no spouse or children survive the deceased member,

any dependent parent may be eligible for benefits.

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Additional Benefit Information9

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State group insuranceA member must be vested to qualify for state health insurance after retirement. The state pays 100% insurance premiums for the member if they have 20 or more years of service. The member will be charged at the same rate for their dependents as when they were active employees.

All members with less than 20 years pay a percentage of their group health insurance based on years of state service.

Group insurance coverage is effective on the same date as pension benefits begin, or the date of application, whichever is later.

Members enrolled in Medicare need to send SERS copies of their Medicare cards.

Survivor insurance benefitsWhen an active employee dies, your agency handles the deceased member’s Group Life Insurance claim, and terminates their insurance coverage. SERS processes the group insurance enrollment of the certified eligible survivors.

SERS picks up group insurance coverage for survivors on the same date as the survivor benefit begins, or the date of application, whichever is later. Contact our office if you have questions about this procedure.

Other insuranceMembers can make payroll deductions for other types of non-group insurance. Members must submit an authorization for payroll deduction card to SERS showing the effective date of the authorization.

Non-group insurance policy deductions cannot be taken from the first check issued. At least two direct payments to the insurance carrier by the member are required for continued coverage. If the member submitted deduction cards to SERS, the deductions should appear on the second check issued.

It is the employee’s responsibility to make provisions for continued coverage of other non-group insurance until SERS adds them to the benefit rolls.

TAX INFORMATIONTaxation of benefitsAll benefits are exempt from Illinois income tax, but members can request to have federal taxes withheld. Members will pay federal income tax on all SERS benefits, with the exception of occupational death and occupational disability benefits.

Taxation of pensionsPension benefits are subject to federal income tax. A portion of each benefit payment is taxable, and a portion is nontaxable, based on the member’s age and the amount of nontaxable contributions. The entire amount of the benefit above any non-taxable contributions is taxable.

The Comptroller’s office will send a Form 1099-R each January to use for filing state and federal taxes.

If the retiree dies and there is no eligible survivor or nominated beneficiary to receive death benefits, the remaining member contributions made before Jan. 1, 1982 may be used as a deduction on the deceased member’s final tax return.

Taxation of disability benefitsOccupational disability benefits paid by SERS are exempt from both federal and Illinois income tax. However, they must be reported on the recipient’s tax return.

Nonoccupational and temporary disability benefits are exempt from Illinois income tax, but are subject to federal income tax. A Form 1099-R is sent to all disability recipients each January from the Comptroller’s office.

GROUP INSURANCE

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Taxation of survivors/widow’s benefitsThe monthly benefit paid to a survivor or widow, as well as any lump-sum payment, is subject to federal income tax. A portion of each payment is nontaxable, based on the survivor or widow’s age and the amount of nontaxable contributions. After the nontaxable contributions are depleted, the entire benefit is taxable. The Comptroller’s office will send all survivors a Form 1099-R each January.

After the death of the survivor or widow, and no further benefits are payable, the remaining nontaxable contributions may be used as a deduction on the deceased survivor or widow’s final tax return. Beneficiaries should consult their local IRS office or tax advisor for help in understanding their tax liability.

Lump-sum paymentsLump-sum payments include: •Nonoccupationaldeathbenefit •Nonoccupationaldeathbenefit

after retirement •Refundof contributions •WidoworSurvivor’scontributionrefund •Alternativeformulacontributionrefund

All lump-sum payments from SERS are exempt from Illinois income tax, but are subject to federal income tax. The amount of the lump-sum payment subject to income tax or eligible for a rollover includes the member’s contributions and interest made after Dec. 31, 1981.

These lump-sum distributions are subject to a mandatory 20% withholding if a member or surviving spouse receives them. The Comptroller’s office will send a 1099-R form the following January of the year the member receives payment.

RolloversAn individual can avoid current taxation on a lump-sum payment by rolling that portion into another qualified employer retirement plan that accepts rollovers, or into an IRA, which is a pre-tax individual retirement account.

Members can ask SERS to do direct transfers into a new plan or IRAs. If they do not ask SERS to transfer the payment directly, the member can still rollover the taxable amount to a new plan or IRA within 60 days after the individual receives the payment.

The Secretary of the Treasury has the authority to waive the 60-day rollover limit in the case of casualty, disaster or uncontrollable events. The individual must notify the new plan or the IRA about the rollover.

10% Early Distribution Tax on lump-sum distributionsA refund of contributions after termination of employment before age 55 is subject to a 10% early distribution tax. This tax does not apply to a refund of contributions following termination of employment after age 55, death or disability.

The portion of the refund subject to the 10% early distribution tax is the excess of the employee’s contributions that they did not roll over. Employees can find additional information on in the SERS Tax Information brochure, or by contacting the local IRS Office.

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Social Security planningTo get an overview of the Social Security Programs, call 1-800-772-1213 and ask for the pamphlet, “Understanding Social Security.”

Members can receive a Social Security satement by printing and completing Form SSA-7004 and mailing it to the address on the form. This shows members’ estimated Social Security retirement, survivor and disability benefits. It will also verify the number of credits with Social Security and earnings credited to the member’s record.

The basic purpose of Social Security benefits is to replace partial income lost due to disability, death or retirement. It is not designed to replace income. Members need to know what Social Security will provide, then design other insurance, savings and investments around this basic plan.

Social Security benefitsIf a member becomes totally disabled, benefits will be paid to them and their family while they are disabled. If they return to work despite their disability, there are work incentives that allow them to try a different job before losing the Social Security monthly benefit. Members who receive disability for 24 months become eligible for Medicare.

All coordinated members of SERS need to file for Social Security benefits when they apply for SERS benefits. If a member dies, their family becomes eligible for Social Security benefits. SERS pensions generally do not affect Social Security survivor benefits.

A member may begin receiving Social Security retirement benefits as early as age 62 if they paid into Social Security for at least 10 years.

Any benefits taken before age 65 are permanently reduced. If members delay retiring until after age 65, they will receive delayed retirement credits, which will increase their monthly retirement benefit.

Social Security & SERS disabilitySocial Security pays disability benefits if a person is unable to “engage in substantial gainful activity” resulting from physical or mental impairment lasting, or expecting to last, for one or more years.

Like Social Security retirement benefits, Social Security disability benefits are determined by average wages earned over a period.

If a member does not pay into Social Security as a State employee, their disability benefits from SERS are not affected. However, if they do pay into Social Security, their Social Security disability payments will affect the SERS nonoccupational disability benefit.

Social Security death benefitsSocial Security provides two benefits when a covered employee dies: •Alump-sumpaymentof $255ispaidtoawidowor

dependents eligible for a child’s benefit. •Asurvivor’sbenefitispayabletothesurviving

spouse, if that spouse is over age 62. The amount of that benefit is 82.5% of what the employee would have been paid at retirement (100% if the spouse is over 65).

•Asurvivor’sbenefitispayabletoeachsurvivingchild under age 18 (age 22 if full-time student). The amount of this benefit is 75% of what the employee would have been paid at retirement.

SOCIAL SECURITY

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Social Security retirement benefitsRetirement benefits are based on the average salary over a 40 year working period. Social Security uses the 35 highest years, indexed for inflation, and provides a percentage of that salary to the individual. The percentage is higher for lower wage earners and lower for higher wage earners.

For members born after 1937, the age when they can receive full benefits increases over time. For instance, a State employee born in 1952 will be eligible to receive full benefits at age 66.

SERS benefits will not affect Social Security benefits unless the member didn’t pay into Social Security. In that case, the Social Security reduces or eliminates their benefit.

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Sources ofCommunication10

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Annual benefit statementSERS mails active members their annual benefit statement in August, which shows the member’s accumulated contributions and service credit as of June 30. Statements are also available for download on the Member Services website.

This statement (p. 43) gives the member specific information about their SERS account, benefit projections and shows the member’s current beneficiaries.

Inactive members receive an Inactive Benefit Statement each April.

SERS handbook (Tier 1 & 2)The SERS Handbooks, Your Rights & Responsibilities, presents a general explanation of benefits, eligibility requirements, service and contributions. This information applies to all active state employees. If a member terminates employment with the State, the law determines benefits in effect on the last day of employment.

The handbook should be a supplement to the annual benefit statement. SERS mails all new state employees a handbook after they become a member.

We revise handbook as needed, and it’s available on the website for active employees to download and print on-demand.

SERS newslettersSERS publishes two newsletters for members:

We mail the SERS-O-GRAM to active members in April and August.

We mail the Informer to retired members and their beneficiaries in January, March and August.

These newsletters keep members and retirees informed of any legislation that affects their benefits, as well as any information that may be useful for retirement strategy and lifestyle.

NewsFlashThe NewsFlash is a quick email update to RCs explaining legislation, policies, procedures and other SERS topics.

SERS field representativesOur field representatives are available in Springfield and Chicago to help all Retirement coordinators with questions as well as conducting benefit seminars and other programs explaining SERS benefits.

SERS designs benefit seminars to help our members understand their rights and responsibilities as members of SERS. Seminars focus on disability, death and retirement benefits, along with a presentation on the Deferred Compensation program. SERS also holds After Dark sessions for second and third shift members.

To schedule a benefit seminar, an After Dark session or meeting, call 217-785-6979.

Payroll bulletinsPayroll bulletins are created by the Accounting Division to inform RCs and Payroll Coordinators of topics such as employer contribution rates, annual salary limitations, etc. These bulletins are specific to payroll information.

PUBLICATIONS

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Preretirement workshopsActive members register for preretirement workshops online at srs.illinois.gov. Once the Retirement coordinator approves the member’s electronic request to attend the workshop, the member receives an email with the registration approval and additional email reminders with details of the workshop.

Investing in Your Future (IYF):We designed this one-day class for members under age 45. The program emphasizes awareness and management of financial and lifestyle risks, using the services of SERS, money management and investing early for the future. Participants also receive a workbook full of information and worksheets.

Education for Tomorrow’s Choices (ETC): This two-day workshop is for members who are 5-15 years from retirement. The ETC stresses medium-range planning for participants to assess their future needs and lifestyle so they can take the necessary steps to achieve their goals.

The ETC focuses on financial planning, entitlements from SERS and Social Security, estate planning, role changes in retirement, health and leisure, and living arrangements.

Countdown to Retirement (CDR): This one-day class is for members who will retire within the next three years. The CDR helps participants assess their immediate retirement plans and take the necessary steps to make the transition from employment to retirement as smooth as possible. It reviews SERS entitlements and Social Security, stresses continuous financial planning and keeping their estate current.

State police workshopsThis one-day workshop is for members who are sworn officers. Registration is not accessible through the website. Any sworn officer wanting to attend a workshop can contact the agency RC or or the Field Services Division for registration.

Annuitant workshopsMyths and Realities of Retirement (MRR): This one-day workshop is for SERS retirees, their survivors, disability benefit recipients and their guests.

The primary aim of the MRR is to help retirees in their continuing quest for satisfaction in retirement. It reviews financial and estate planning, Social Security benefits, group insurance updates and other items of interest. There are lectures by resource personnel on each topic, plus a self-assessment workbook.

Retirees are able to register for the MRR workshop online at srs.illinois.gov. If a retiree does not have access to a computer, they can complete and mail the workshop reservation form that is included in the SERS Informer or MRR workshop brochure, or they can call SERS directly and register. If a retiree does not have an email address to provide, SERS will mail a reminder letter to the retiree within two weeks of the workshop.

WORKSHOPS

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Workshop reservation processEmployees may register for a preretirement workshop at srs.illinois.gov. Prior to registering for a workshop, participants must have approval from their immediate supervisor to attend the workshop.

For participants to register for a workshop, they will do the following steps:

•Visitsrs.illinois.gov. •Clickon“StateEmployeesRetirementSystem,”

which will take them to the main SERS page. •Clickonthe“Workshop Registration” logo (shown

below).

•Clickontheregistrationlinkforthecurrentyear’sworkshops.

•Selecttheworkshopthey’dliketoregisterforbyclicking the link under the “Upcoming Event” column.

•Oncethey’reintheevent,clickthe“registernow”link.

52 srs.illinois.gov

The employee will now complete the registration form.

The information required includes: •Immediatesupervisorname •Name •Homeaddress •Phonenumber •Birthdate •Lastfourdigitsof SocialSecuritynumber •Emailaddress(workemailrecommended) •Agencyname •Approver’semailaddress* •Totalnumberof peopleattending •Guestbox(if applicable)

* On the registration form, it will ask for approver’s email address. In this drop down field, the employee will scroll through and find the name of their agency and Retirement coordinator.

If an employee isn’t sure who their Retirement coordinator is, they can find that information on their annual benefit statement, or contact their agency personnel department or SERS.

Once the employee has completed the online registration form and has pressed the “Submit” button, a pop up window will appear stating the member submitted their registration to the Retirement coordinator for approval.

(Note: If the pop-up window does not appear after the employee submits the registration, the employee will need to complete the registration again, because the registration did not submit properly.)

A similar email is also sent to the employee (at the email address the employee provided), notifying them that the registration has been electronically sent to the Retirement coordinator for approval process. Once the Retirement coordinator approves or denies the employee’s request to attend the workshop, the employee will receive an email with the registration approval or denial. If approved, the employee will receive two reminders – the first two weeks prior and the second reminder two days prior to the workshop – including details such as date, location, times and agenda.

If you have any questions about the registration process, call SERS at 217-785-6979.

Workshop attendanceTo make sure active members attend the entire workshop, SERS trainers have members sign their name on the sign-in sheet prior to the last speaker’s presentation. (For the two-day Education for Tomorrow’s Choices, participants need to sign the attendance sheet both days.) At the end of the workshop, the SERS trainer enters either “absent” or “attended” in the ABC Registration System for the workshop. The member then receives an email confirming their attendance at the workshop, including a certificate of attendance. This confirmation serves as documentation of the employee’s attendance at the workshop, and members may forward to their supervisor and/or Retirement coordinator as proof of attendance.

Within the attendance confirmation email, the participant also receives an evaluation to assess the workshop. We base questions on speakers, objectives, future planning, etc.

srs.illinois.gov 53

Appendix11

54 srs.illinois.gov

srs.illinois.gov 55

Communications

56 srs.illinois.gov

srs.illinois.gov 57

2016 statements Statement of Accounts (as of June 30, 2016) will be mailed mid-August. They are also available on our Member Services website, which we will be notifying members of via email in the next few days. Workshop schedule The 2017 pre-retirement workshop schedule is listed in the current SERS-O-GRAM included with the statements, and we encourage those of you who have not attended to register. These programs are very beneficial to planning your financial security. Forms and applications When completing any form on behalf of your employees, please be sure you are using the most current version of the form by checking our website regularly and printing from there rather than keeping a supply of printed forms. Call center coming We are pleased to announce the future addition of a call center to answer incoming member phone calls. We anticipate the call center to be opening around the first of the year. Website Please be sure to remind your staff to sign up for our Member Services website by following the easy instructions here.

58 srs.illinois.gov

The newsletter for annuitants of the State Employees’ Retirement System of I l l inoisInformerInformerThe

SEPTEMBER 2016srs.illinois.gov

Keep your Member Services contact information up-to-date to receive the latest news, announcements or deadlines by email, text or call.

2101 S. Veterans Parkway P. O. Box 19255Spring eld, IL 62794-9255217-785-7444

STATE RETIREMENTSYSTEMS

Life beyond retirement – what now?You may be a new retiree or a seasoned veteran by now. Often we dream of retirement throughout our careers. We plan, save and imagine what we’ll do with all our free time. But when the time comes, sometimes it’s a harder adjustment than we thought it might be.

Forbes’ Mike Lewis wrote about this subject in his article “Life After Retirement – What Do I Do Now?,” quoting a May 2013 study by UK’s Institute of Economic Affairs who reported a stunning statistic: 40% of retirees suffer from clinical depression, while 6 out of 10 report a decline in health.

Lewis’s article spoke of these individuals nding themselves bored and void of feelings and skills they’d experienced on the job – such as feeling appreciated and contributing, problem solving and camaraderie with coworkers. However, these don’t have to be lost when we leave the workplace. These are all healthy bene ts that can be carried into retirement as well.

Make peace with yourselfYou have been given the gift of unburdened time. Use it to re ect on your accomplishments, make peace with the things you’re not as happy about and allow yourself to move on with your new life. Perspective is key when it comes to perceived mistakes.

Be socialFind groups with interests similar to yours, whether that be volunteer work, hobbies, happy hours or exercise groups. With social media introducing new ways to connect, the possibilities are endless.

Be philanthropicRemember that cause that’s always been near and dear to your heart? Devote some time to helping that cause. Organize fundraisers, or do research projects for the foundation.

Whatever you choose to do, remember to enjoy it, you’ve earned it!

Keep your address current to receive benefit informationIt’s important to notify SERS of address changes to be sure you’re always receiving the most current information regarding your insurance and retirement bene ts. If we have correspondence returned to us, your bene t and group insurance will be suspended until we are noti ed of your new address to avoid any potential fraud issues.

Please mail address changes to us via the Change of Address Form, which can be found on our website, srs.illinois.gov, under the Forms link.

If you don’t have access to a computer, we can accept written noti cation of an address change as long as it includes your printed name, date of birth, last four digits of your Social Security number (or Member Identi cation Number), former and current addresses, telephone number and your signature.

New SERS TrusteeCongratulations to John Tilden, elected annuitant trustee.

srs.illinois.gov 59

The n e w s l e t t e r fo r m e m b e r s o f t h e S t a t e E m p l o y e e s ’ R e t i rement S y s t e m o f I l l i n o i s

www.srs.illinois.gov

S E R S - O - G R A MS E R S - O - G R A MThe2101 S. Veterans Parkway P. O. Box 19255Spring eld, IL 62794-9255217-785-7444

STATE RETIREMENTSYSTEMS

Estimated retirement benefit calculationsThe amount of service credit (shown in both months and years) and your Final Average Compensation (FAC) as of 06/30/2016 are displayed in the top section of the front page of your membership statement.

It is important to note the estimated retirement bene t shown on your statement is calculated using projected future service credit and earnings, based on the projected nal average compensation. The table below details the FAC calculation that is applicable to SERS members depending on their speci c Tier (1 or 2) and the bene t formula (regular or alternative) for which they are eligible.

Tier 1 Tier 2Regular Regular

• Average monthly salary based on the highest 48 consecutive months of earnings out of the last 120 months.


Alternative Alternative

• For members certi ed in an alternative formula position prior to Jan. 1, 1998, your FAC will be the highest of: • the average monthly salary

based on the highest 48 consecutive months of earnings out of the last 120 months; OR

• average of last 48 months of earnings; OR

• final rate of pay.

• For members certi ed in an alternative formula position Jan. 1, 1998 or later, your FAC will be the highest of:

• average of last 48 months of earnings; OR

• final rate of pay.


The FAC shown on your statement is affected directly by your earnings history. For the majority of SERS members, the FAC calculated and shown on the annual statement is lower than (or equal to) the monthly rate of pay. For members in positions that require a lot of overtime, the FAC is generally greater than the monthly rate of pay.

NCPERS open enrollment: Oct. 1 – Nov. 30, 2016The State Retirement Systems (SRS) offers a voluntary life insurance plan to its members through the National Conference of Public Employee Retirement Systems (NCPERS).

SRS is offering an open enrollment period for the voluntary group life insurance coverage to our actively working members. The enrollment period will be held Oct. 1, 2016 – Nov. 30, 2016.

There is no guarantee that another open enrollment period will be offered in the future, and you can only enroll while actively working. There will be no mailing to announce the open enrollment period, so please mark your calendars.

You can access an enrollment/bene ciary form on Oct. 1, 2016 by going to www.ncpersvoluntarylife.com/srs.

Your benefit statementEnclosed with this active SERS-O-GRAM is your current bene t statement. This statement contains detailed information about your SERS bene ts as of June 30, 2016.

You may change your bene ciaries at any time by completing and ling the enclosed form with SERS.

If you have questions about bene ciaries, call us at 217-785-6973.

Keep your Member Services contact information up to date to receive the latest news, announcements or deadlines by email, text or call.

AUGUST 2016

Check out our Member Services websitehttps://memberservices.srs.illinois.gov

60 srs.illinois.gov

Service Forms

REQUEST TO ESTABLISH SERVICE CREDITS PRIOR TO DATE OF MEMBERSHIP

Name of Employee S.S. No.

Address Date of Birth: Street Month Day Year

City State Zip Home Phone Work Phone + Ext

Name as shown on payroll at time of any State employment

Please indicate by checking the appropriate box the type of service credit for which you are requesting information and complete the blanks for the corresponding box. Sign and date the form on the reverse side.

1. QUALIFYING PERIOD (12 months preceding date of membership prior to 1/1/1972 or 6 months for a person entering state service on or after 1/1/1984 through 11/30/2010.)

Beginning date of employment:

2. SHORT PERIODS - Intermittent periods of service which did not exceed a qualifying period for which no deductions were taken for retirement.

DATES OF EMPLOYMENT From To Agency/Department Month Year Month Year _______ _______ _______ _______ _____________________________________ _______ _______ _______ _______ _____________________________________ _______ _______ _______ _______ _____________________________________ _______ _______ _______ _______ _____________________________________

3. LEAVE OF ABSENCE (L.O.A.) (Periods of less than one year spent on an authorized leave of absence from service, provided that the period of leave began on or after January 1,1982 and any credit established by the member for the period of leave in any other public employee retirement system has been terminated.)3a. Leave of absence/Final average compensation: A member may elect to establish earnings credit for an authorized leave of absence within 48 months after returning to work from the leave.

DATES OF L.O.A. From To Agency/Department Service Credit Earnings Month Year Month Year (check either one or both) _______ _____ _______ _____ ___________________ _______ _____ _______ _____ ___________________ _______ _____ _______ _____ ___________________ _______ _____ _______ _____ ___________________

2003 (R-3-13) IL 589-0170 - OVER -

Agency/Department

Day YearMonth

4. MILITARY SERVICE: Attach copy of Form DD 214 or appropriate separation or discharge papers verifying active duty for either purchased or free military service credit. The form MUST indicate the type of separation, i.e. honorable discharge.

A member may purchase up to 48 months of active duty; or receive free military service credit. To receive free military, a member must have been a state employee within six months immediately prior to entry into military service, and return to state employment within 15 months after an honorable discharge. The mem-ber must establish the state service credit before and after the military service.

Free Military: a) Name of Agency and Department prior to entry into military service:________________________ b) Last date of state employment prior to entry into military service:___________________________ c) Name of Agency and Department following discharge from military service:__________________ d) Beginning date of employment following discharge from military service:____________________

5. REPAYMENT OF REFUND(S)* - Employee required to have 2 years of contributing service subsequent to refund either in the State Employees' Retirement System and/or reciprocal system.

a) Date(s) of refund(s)

b) Date(s) returned to work

c) Agency/Department(s) where employed

* A member who has met the two year contributing service requirement may wish to purchase all of their refund or a portion. If part of the refund is repaid, the member may choose to repay additional whole months or all of the remaining portion at a later date. I wish to purchase the entire refund(s). I wish to purchase _____________ whole months

6. INTERNSHIPS - Below are the only internships that may be purchased. a) Illinois Legislative Staff Internships Program. Dates: ____________________________________ b) Government Public Service Internship Program (GPSI). Dates:____________________________

7. DO YOU PLAN TO RETIRE IN THE NEAR FUTURE? Yes No

If yes, when ________________

THIS SECTION IS OPTIONAL

___________________________________________________ _________________________ Member's Signature Date

METHOD OF PAYMENT

a) Lump sum

b) Direct pay installment option (minimum $20 per payment)

c) Post-tax payroll deduction installment option (minimum $10 per pay period)

d) Tax deferred irrevocable payroll deduction option (minimum $10 per pay period)

e) Tax deferred lump sum sick and vacation payment

f) Deferred Compensation Transfer (The account must have enough funds to cover the total amount due.)

d) Name of Reciprocal System (if applicable)

YearMonth

YearMonth

YearMonth

YearMonth

STATE RETIREMENT SYSTEMS

State Employees' Retirement System of Illinois General Assembly Retirement SystemJudges' Retirement System of Illinois

2101 South Veterans Parkway, P.O. Box 19255, Springfield, IL 62794-9255Internet: http://www.srs.illinois.gov E-Mail: [email protected]

srs.illinois.gov 61

REQUEST TO ESTABLISH SERVICE CREDITS PRIOR TO DATE OF MEMBERSHIP

Name of Employee S.S. No.

Address Date of Birth: Street Month Day Year

City State Zip Home Phone Work Phone + Ext

Name as shown on payroll at time of any State employment

Please indicate by checking the appropriate box the type of service credit for which you are requesting information and complete the blanks for the corresponding box. Sign and date the form on the reverse side.

1. QUALIFYING PERIOD (12 months preceding date of membership prior to 1/1/1972 or 6 months for a person entering state service on or after 1/1/1984 through 11/30/2010.)

Beginning date of employment:

2. SHORT PERIODS - Intermittent periods of service which did not exceed a qualifying period for which no deductions were taken for retirement.

DATES OF EMPLOYMENT From To Agency/Department Month Year Month Year _______ _______ _______ _______ _____________________________________ _______ _______ _______ _______ _____________________________________ _______ _______ _______ _______ _____________________________________ _______ _______ _______ _______ _____________________________________

3. LEAVE OF ABSENCE (L.O.A.) (Periods of less than one year spent on an authorized leave of absence from service, provided that the period of leave began on or after January 1,1982 and any credit established by the member for the period of leave in any other public employee retirement system has been terminated.)3a. Leave of absence/Final average compensation: A member may elect to establish earnings credit for an authorized leave of absence within 48 months after returning to work from the leave.

DATES OF L.O.A. From To Agency/Department Service Credit Earnings Month Year Month Year (check either one or both) _______ _____ _______ _____ ___________________ _______ _____ _______ _____ ___________________ _______ _____ _______ _____ ___________________ _______ _____ _______ _____ ___________________

2003 (R-3-13) IL 589-0170 - OVER -

Agency/Department

Day YearMonth

4. MILITARY SERVICE: Attach copy of Form DD 214 or appropriate separation or discharge papers verifying active duty for either purchased or free military service credit. The form MUST indicate the type of separation, i.e. honorable discharge.

A member may purchase up to 48 months of active duty; or receive free military service credit. To receive free military, a member must have been a state employee within six months immediately prior to entry into military service, and return to state employment within 15 months after an honorable discharge. The mem-ber must establish the state service credit before and after the military service.

Free Military: a) Name of Agency and Department prior to entry into military service:________________________ b) Last date of state employment prior to entry into military service:___________________________ c) Name of Agency and Department following discharge from military service:__________________ d) Beginning date of employment following discharge from military service:____________________

5. REPAYMENT OF REFUND(S)* - Employee required to have 2 years of contributing service subsequent to refund either in the State Employees' Retirement System and/or reciprocal system.

a) Date(s) of refund(s)

b) Date(s) returned to work

c) Agency/Department(s) where employed

* A member who has met the two year contributing service requirement may wish to purchase all of their refund or a portion. If part of the refund is repaid, the member may choose to repay additional whole months or all of the remaining portion at a later date. I wish to purchase the entire refund(s). I wish to purchase _____________ whole months

6. INTERNSHIPS - Below are the only internships that may be purchased. a) Illinois Legislative Staff Internships Program. Dates: ____________________________________ b) Government Public Service Internship Program (GPSI). Dates:____________________________

7. DO YOU PLAN TO RETIRE IN THE NEAR FUTURE? Yes No

If yes, when ________________

THIS SECTION IS OPTIONAL

___________________________________________________ _________________________ Member's Signature Date

METHOD OF PAYMENT

a) Lump sum

b) Direct pay installment option (minimum $20 per payment)

c) Post-tax payroll deduction installment option (minimum $10 per pay period)

d) Tax deferred irrevocable payroll deduction option (minimum $10 per pay period)

e) Tax deferred lump sum sick and vacation payment

f) Deferred Compensation Transfer (The account must have enough funds to cover the total amount due.)

d) Name of Reciprocal System (if applicable)

YearMonth

YearMonth

YearMonth

YearMonth




62 srs.illinois.gov

TO:

FROM: Service & Refunds Division

DATE:

RE:

SSN:

Under the provisions of House Bill 313, the above named member has requested to establish service credit for time spent on an authorized leave of absence. The authorized leave of absence has to be for periods of less than one year and the leave had to begin on or after January 1, 1982. The member may have more than one leave of absence and in that case, the total may exceed one year.

Please complete the following information and return it as soon as possible.

I certify that the above named employee was granted a leave of absence

from _________________________ to _________________________

from _________________________ to _________________________

from _________________________ to _________________________

from _________________________ to _________________________

Date_____________________________________

Signature ____________________________________________________ (SERS Retirement Coordinator or Authorized Designee)

Phone Number _______________________________________________ (SERS Retirement Coordinator or Authorized Designee)

2067 (R-2-11)

TO:

FROM: Service & Refunds Division

DATE:

RE:

SSN:

Under the provisions of House Bill 313, the above named member has requested to establish service credit for time spent on an authorized leave of absence. The authorized leave of absence has to be for periods of less than one year and the leave had to begin on or after January 1, 1982. The member may have more than one leave of absence and in that case, the total may exceed one year.

Please complete the following information and return it as soon as possible.

I certify that the above named employee was granted a leave of absence

from _________________________ to _________________________

from _________________________ to _________________________

from _________________________ to _________________________

from _________________________ to _________________________

Date_____________________________________

Signature ____________________________________________________ (SERS Retirement Coordinator or Authorized Designee)

Phone Number _______________________________________________ (SERS Retirement Coordinator or Authorized Designee)

2067 (R-2-11)



2101 South Veterans Parkway, P.O. Box 19255, Springfield, IL 62794-9255Internet: http://www.state.il.us/srs E-Mail: [email protected]




srs.illinois.gov 63

State Employees’ Retirement System of Illinois2101 South Veterans Parkway P.O. Box 19255, Springfield, IL. 62794-9255 Phone (217) 785-7167

IRREVOCABLE PAYROLL AUTHORIZATION OF PERMISSIVE SERVICE CREDITSOR REDEPOSIT OF CONTRIBUTIONS

A State Employees’ Retirement System (SERS) member, pursuant to statute, is permitted to redeposit member con-tributions previously withdrawn and/or elect to purchase permissive service credit. Any amounts due may generally be paid by the member directly to the retirement system, or the member may request, and the employer may permit, deductions through payroll. These payments through payroll deduction are in addition to any required contributions to SERS.

I understand that the State of Illinois (“my employer”) has adopted a statute under the “pickup” tax deferral provi-sions of Internal Revenue Code Section 414 (h) (2) for payroll deduction and that tax deferral of my redeposit and/or purchase of permissive service requires this irrevocable payroll deduction authorization.

I hereby authorize and understand that this authorization is binding and irrevocable.1. Effective ___________________ deductions are to be made from my salary, for a total of _____ pay

periods in the amount of $ __________ per pay period or until the total amount of $ __________ or the full cost of the permissive service credit is deducted.

Deductions are to be made from my salary as follows: Effective ___________________ deduct $ __________ for _____ pay periods and $ __________ for one pay period or until the total amount of $ __________ or the full cost of the permissive service credit is deducted.

Deduction is to be made from my lump sum sick and vacation payment in the amount of $_________ based on a termination date of _______________ or the full cost of the permissive service credit is paid.

2. For the effective period of this agreement, payments are to be made by my employer. While this agreement is in effect, I understand that SERS will only accept payment from my employer and not directly from me.

3. Myemployerisobligatedtomakepaymentpursuanttothisagreementonlyiftherearesufficientfundsfrommy earnings to do so after any other mandatory deductions.

4. This agreement shall remain in effect only until:

a) payroll deductions are completed, b) death, c) disability, or d) termination of employment.

In the case of death, partial service credit will be granted based upon contributions and interest paid through the date of death. In the case of disability or termination of employment, I will have to choose whether to make the balance of the payments on an after-tax lump sum basis or receive a refund, subject to all appropri-ate tax withholdings.

5. All payments must be made prior to retirement.

I understand that if the monthly deduction authorized in this document becomes 120 days delinquent in whole or in part, for any reason, SERS will cancel this election and refund all payments received subject to tax with-holding to the employee.

Iauthorizetheaboveirrevocablepayrolldeductionsunderconditionsasspecified.

Print Employee’s Name: _____________________________________________________________

Employee Social Security Number: _____________________ Date: _________________

Employee Signature: ____________________________________________________________

2071 (R-3-98)

State Employees’ Retirement System of Illinois2101 South Veterans Parkway P.O. Box 19255, Springfield, IL. 62794-9255 Phone (217) 785-7167


A State Employees’ Retirement System (SERS) member, pursuant to statute, is permitted to redeposit member con-tributions previously withdrawn and/or elect to purchase permissive service credit. Any amounts due may generally be paid by the member directly to the retirement system, or the member may request, and the employer may permit, deductions through payroll. These payments through payroll deduction are in addition to any required contributions to SERS.

I understand that the State of Illinois (“my employer”) has adopted a statute under the “pickup” tax deferral provi-sions of Internal Revenue Code Section 414 (h) (2) for payroll deduction and that tax deferral of my redeposit and/or purchase of permissive service requires this irrevocable payroll deduction authorization.

I hereby authorize and understand that this authorization is binding and irrevocable.1. Effective ___________________ deductions are to be made from my salary, for a total of _____ pay

periods in the amount of $ __________ per pay period or until the total amount of $ __________ or the full cost of the permissive service credit is deducted.

Deductions are to be made from my salary as follows: Effective ___________________ deduct $ __________ for _____ pay periods and $ __________ for one pay period or until the total amount of $ __________ or the full cost of the permissive service credit is deducted.

Deduction is to be made from my lump sum sick and vacation payment in the amount of $_________ based on a termination date of _______________ or the full cost of the permissive service credit is paid.


3. Myemployerisobligatedtomakepaymentpursuanttothisagreementonlyiftherearesufficientfundsfrommy earnings to do so after any other mandatory deductions.

4. This agreement shall remain in effect only until:

a) payroll deductions are completed, b) death, c) disability, or d) termination of employment.

In the case of death, partial service credit will be granted based upon contributions and interest paid through the date of death. In the case of disability or termination of employment, I will have to choose whether to make the balance of the payments on an after-tax lump sum basis or receive a refund, subject to all appropri-ate tax withholdings.

5. All payments must be made prior to retirement.

I understand that if the monthly deduction authorized in this document becomes 120 days delinquent in whole or in part, for any reason, SERS will cancel this election and refund all payments received subject to tax with-holding to the employee.


Print Employee’s Name: _____________________________________________________________

Employee Social Security Number: _____________________ Date: _________________

Employee Signature: ____________________________________________________________

2071 (R-3-98)

64 srs.illinois.gov

Request for a Refund Request for a RefundIf you have been separated (resignation, discharge, dismissal or layoff) from state employment for at least 14 days, you are eligible for a refund of your SERS employee contributions. You forfeit all SERS rights and benefits when you accept a refund, but if you later return to state employment in a position covered by SERS, you may repay the refund after establishing two years of SERS service credit.

The form must be completed and submitted, along with a copy of your photo ID before your refund can be processed.

If you have been separated (resignation, discharge, dismissal or layoff) from state employment for at least 14 days, you are eligible for a refund of your SERS employee contributions. You forfeit all SERS rights and benefits when you accept a refund, but if you later return to state employment in a position covered by SERS, you may repay the refund after establishing two years of SERS service credit.

The form must be completed and submitted, along with a copy of your photo ID before your refund can be processed.

State Employees’ Retirement System State Employees’ Retirement System

State Employees’ Retirement SystemState Employees’ Retirement System

State Employees’ Retirement System

SERSState Employees’ Retirement System

SERS





SERS

2101 South Veterans ParkwayP.O. Box 19255Springfield, IL 62794-9255


srs.illinois.gov srs.illinois.gov

217-785-7444 Fax: 217-785-6964Email: [email protected]

217-785-7444 Fax: 217-785-6964Email: [email protected]

Refund election (check ONE box)If you do not make an election, we will pay the refund directly to you, withholding federal taxes at a rate of 20%. In addition, if you are under age 55 and do not rollover your refund to a qualified plan, your refund will be subject to a 10% early distribution tax, due April 15 the following year.

o I want the entire refund issued directly to me. I understand 20% of the taxable portion will be withheld for federal income tax;

o I want my entire refund transferred directly to the retirement plan listed below; (You must fill out the section below if you choose this option.) OR

o I want $_________________ of the taxable portion of my refund transferred directly to the retirement plan listed below and the remainder issued to me. I understand 20% of any taxable amount not rolled over will be withheld for federal income tax. (You must fill out the section below if you choose this option.)

Refund election (check ONE box)If you do not make an election, we will pay the refund directly to you, withholding federal taxes at a rate of 20%. In addition, if you are under age 55 and do not rollover your refund to a qualified plan, your refund will be subject to a 10% early distribution tax, due April 15 the following year.

o I want the entire refund issued directly to me. I understand 20% of the taxable portion will be withheld for federal income tax;

o I want my entire refund transferred directly to the retirement plan listed below; (You must fill out the section below if you choose this option.) OR

o I want $_________________ of the taxable portion of my refund transferred directly to the retirement plan listed below and the remainder issued to me. I understand 20% of any taxable amount not rolled over will be withheld for federal income tax. (You must fill out the section below if you choose this option.)

Retirement plan accepting rolloverFinancial Institution qualified to accept the rollover (limit of one institution) c IRA c 401(k) c 403(b) c Other

IRA/Retirement plan account number _____________________________________________________________________

Name ____________________________________________________ Phone _________________________________

Address ___________________________________________________________________________________________

City __________________________________________________ State ________ Zip Code _________________

Retirement plan accepting rolloverFinancial Institution qualified to accept the rollover (limit of one institution) c IRA c 401(k) c 403(b) c Other

IRA/Retirement plan account number _____________________________________________________________________

Name ____________________________________________________ Phone _________________________________

Address ___________________________________________________________________________________________

City __________________________________________________ State ________ Zip Code _________________

By accepting a refund, I forfeit all accrued rights and benefits of the State Employees’ Retirement System for myself and my beneficiaries. I certify this information is correct. I am aware that pursuant to the 40 ILCS 5/1-135 any person who knowingly makes a false statement or falsifies a record in an attempt to defraud SERS is guilty of a Class 3 felony. If the SERS Board of Trustees has a reasonable suspicion that an attempt has been made to defraud SERS, it is required to report the matter to the appropriate state’s attorney for investigation.

Member’s Name (Print) _______________________ Member’s Signature ___________________________________

Member’s Social Security Number (Last 4) _________________________ Date _______________________________

Phone number ___________________________ Email __________________________________________________

c Copy of photo ID enclosed

By accepting a refund, I forfeit all accrued rights and benefits of the State Employees’ Retirement System for myself and my beneficiaries. I certify this information is correct. I am aware that pursuant to the 40 ILCS 5/1-135 any person who knowingly makes a false statement or falsifies a record in an attempt to defraud SERS is guilty of a Class 3 felony. If the SERS Board of Trustees has a reasonable suspicion that an attempt has been made to defraud SERS, it is required to report the matter to the appropriate state’s attorney for investigation.

Member’s Name (Print) _______________________ Member’s Signature ___________________________________

Member’s Social Security Number (Last 4) _________________________ Date _______________________________

Phone number ___________________________ Email __________________________________________________

c Copy of photo ID enclosed2000 (04/18) 2000 (04/18)

Refund Forms

srs.illinois.gov 65

Disability forms

3901 (R-1-15) IL 589-0105

C L A I M N O T I F I C A T I O N

1. Complete Agency and Employee information.2. Check appropriate box and provide requested information.3. Any comments relative to this notification may be furnished in the "COMMENTS" section at the bottom of the form.

AGENCY EMPLOYEE

Name of Agency Social Security Number

Coordinator's Signature Name

Coordinator's Telephone # Address

Home #________________ Work #________________

PENSION Planned retirement date ______________________________ Is member married? Yes _____ No _____ Date: _________________ Does member have children under age 18 or dependent children over age 18 who are disabled? Yes _____ No _____ Does member have unmarried children 18-22 who are full time students? Yes_____ No____

PENSION Base estimate on:ESTIMATE Date of separation from state service________________________________ Effective date of retirement________________________________________ Unpaid/Unused sick days_________________________________________ Paid sick & vacation days_________________________________________ Level income option: Social Security estimate age 62 ______ Full retirement age ________

NON-OCCUPATIONAL Date last worked________________________________________________DISABILITY Date leave of absence begins______________________________________ Maternity? Yes _____ No _____ Did employee leave status change because TTD benefits stopped? Yes_____ No____

OCCUPATIONAL Date of accident________________________________________________DISABILITY Date removed from payroll________________________________________

DEATH Date of death__________________________________________________ Is member married? Yes _____ No _____ Date:___________________ Was death service-connected? Yes _____ No _____ Does member have children under age 18 or dependent children over age 18 who are disabled? Yes _____ No _____ Does the member have unmarried children 18-22 who are full time students? Yes____ No ____Name and address of next of kin:______________________________________________________________________________________________________________________________________________________________________________

COMMENTS:

City ZipState

3901 (R-1-15) IL 589-0105

C L A I M N O T I F I C A T I O N

1. Complete Agency and Employee information.2. Check appropriate box and provide requested information.3. Any comments relative to this notification may be furnished in the "COMMENTS" section at the bottom of the form.

AGENCY EMPLOYEE

Name of Agency Social Security Number

Coordinator's Signature Name

Coordinator's Telephone # Address

Home #________________ Work #________________

PENSION Planned retirement date ______________________________ Is member married? Yes _____ No _____ Date: _________________ Does member have children under age 18 or dependent children over age 18 who are disabled? Yes _____ No _____ Does member have unmarried children 18-22 who are full time students? Yes_____ No____

PENSION Base estimate on:ESTIMATE Date of separation from state service________________________________ Effective date of retirement________________________________________ Unpaid/Unused sick days_________________________________________ Paid sick & vacation days_________________________________________ Level income option: Social Security estimate age 62 ______ Full retirement age ________

NON-OCCUPATIONAL Date last worked________________________________________________DISABILITY Date leave of absence begins______________________________________ Maternity? Yes _____ No _____ Did employee leave status change because TTD benefits stopped? Yes_____ No____

OCCUPATIONAL Date of accident________________________________________________DISABILITY Date removed from payroll________________________________________

DEATH Date of death__________________________________________________ Is member married? Yes _____ No _____ Date:___________________ Was death service-connected? Yes _____ No _____ Does member have children under age 18 or dependent children over age 18 who are disabled? Yes _____ No _____ Does the member have unmarried children 18-22 who are full time students? Yes____ No ____Name and address of next of kin:______________________________________________________________________________________________________________________________________________________________________________

COMMENTS:

City ZipState







Date

Tier 1 Tier 2Date

Tier 1 Tier 2

66 srs.illinois.gov

Instructions for Completing Employer Statement

1. Type of claim – Complete by checking appropriate box for type of claim received.

2. Last date employee worked – Indicate the last date that the employee was present and worked.

3. (a) Last day salary or wages due employee – Indicate the last day employee earned normal pay. In the case of medical leave of absence, indicate the last day employee earned pay (could be sick or vacation pay).

(b) Date employee removed from payroll – Indicate the pay period ending date of when employee was removed from payroll.

(c) Has employee returned to work? – Complete by checking the appropriate box. If yes, indicate the physical return to work date.

4. Reason for removal – Complete this section by checking the appropriate box and indicate the ef-fective date of the removal. The effective date of action is the actual date of event. If this is a death claim for an active member or inactive member, it is important to answer “yes or no” regarding medical leave of absence at death.

5. Unused sick days – Complete this section by indicating the number of unused sick days for the specific time period.

6. (a) Employee base rate of pay - Indicate base rate of pay. (b) Employee work status - Complete by checking appropriate box. (c) Employee’s total rate of pay includes base rate of pay plus, longevity, bilingual and permanent

differential. (d) Frequency of Pay - Complete by checking appropriate box.

7. Will a Form 1404 be processed? – Complete by checking the appropriate box. If yes, submit 1404 to the retirement system immediately. Form 1404 is the form used to report paid sick, vacation and personal days being used by the member to establish service credit and the contributions to be withheld from the lump sum payment.

Complete 8 and 9 for Disability Claims only.

8. Has the Employee filed a claim for Workers Compensation benefits? Complete for disability claims only by checking the appropriate box.

9. (a) Is there any indication that this is a work-related disability? Complete by checking the appropri-ate box.

(b) If this is a work related disability, was a 3rd party involved? Complete by checking the appropri-ate box.

The Agency Retirement Coordinator is required to sign, date and list their phone number in case State Retirement System has questions

EMPLOYER STATEMENT

1. Type of claim: Pension Death Occupational Disability Non-Occupational Disability

Date ________________________2. Last day employee physically worked _____ / _____ /__________ 3. (a) Last day salary or wages due employee: _____ / _____ /__________

(b) Date employee removed from payroll, bi-weekly or either the 15th or the end of month: _____ / _____ /__________

(c) Has employee returned to work? Yes No Date returned to work _____ / _____ /__________

4. Reason for removal: Resignation Medical Leave of Absence Discharge/Dismissal Service Connected Leave Layoff Death (Was member on an approved medical leave of absence at death? Yes No)

5. Total unused sick days earned prior to January 1, 1984 .................................................. __________Total unused sick days earned after December 31, 1997 ................................................. __________Total unused sick days earned after December 31, 1983 and before January 1, 1998 .................................................................. ....................__________Less: One-half of unused sick days earned after December 31, 1983 and before January 1, 1998 .................................................................... .....................(__________) __________Number of unused sick days remaining for pension calculation ........................................A + B + C = __________

6. (a) Employee base rate of pay: $ ___________________; (b) Employee work status: Full-Time Part-Time (c) Employee total rate of pay: $____________________; (d) Frequency of pay: monthly semi-monthly bi-weekly hourly

7. Will a Form 1404 (Retirement Contributions on Lump Sum Pay for Sick Leave, Vacation, and/or Personal Days) be processed? Yes No

COMPLETE 8 AND 9 FOR DISABILITY CLAIMS ONLY

8. Has the employee filed a claim for Worker's Compensation benefits? Yes No

9. (a) Is there any indication that this is a work-related disability? Yes No (b) If yes, was a 3rd party involved ? Yes No

Retirement Coordinator's Signature ______________________________________________________________

Date ________________________ Phone Number ____________________________ Extension Number__________

3900 (R-10-14) IL 589-0108 (See reverse side for instructions)

AB

C

Month Day Year




Effective date of Action_____ / _____ /__________

Month Day Year

Month Day Year

Month Day Year

Month Day Year

srs.illinois.gov 67

Instructions for Completing Employer Statement

1. Type of claim – Complete by checking appropriate box for type of claim received.

2. Last date employee worked – Indicate the last date that the employee was present and worked.

3. (a) Last day salary or wages due employee – Indicate the last day employee earned normal pay. In the case of medical leave of absence, indicate the last day employee earned pay (could be sick or vacation pay).

(b) Date employee removed from payroll – Indicate the pay period ending date of when employee was removed from payroll.

(c) Has employee returned to work? – Complete by checking the appropriate box. If yes, indicate the physical return to work date.

4. Reason for removal – Complete this section by checking the appropriate box and indicate the ef-fective date of the removal. The effective date of action is the actual date of event. If this is a death claim for an active member or inactive member, it is important to answer “yes or no” regarding medical leave of absence at death.

5. Unused sick days – Complete this section by indicating the number of unused sick days for the specific time period.

6. (a) Employee base rate of pay - Indicate base rate of pay. (b) Employee work status - Complete by checking appropriate box. (c) Employee’s total rate of pay includes base rate of pay plus, longevity, bilingual and permanent

differential. (d) Frequency of Pay - Complete by checking appropriate box.

7. Will a Form 1404 be processed? – Complete by checking the appropriate box. If yes, submit 1404 to the retirement system immediately. Form 1404 is the form used to report paid sick, vacation and personal days being used by the member to establish service credit and the contributions to be withheld from the lump sum payment.

Complete 8 and 9 for Disability Claims only.

8. Has the Employee filed a claim for Workers Compensation benefits? Complete for disability claims only by checking the appropriate box.

9. (a) Is there any indication that this is a work-related disability? Complete by checking the appropri-ate box.

(b) If this is a work related disability, was a 3rd party involved? Complete by checking the appropri-ate box.

The Agency Retirement Coordinator is required to sign, date and list their phone number in case State Retirement System has questions

EMPLOYER STATEMENT

1. Type of claim: Pension Death Occupational Disability Non-Occupational Disability

Date ________________________2. Last day employee physically worked _____ / _____ /__________ 3. (a) Last day salary or wages due employee: _____ / _____ /__________

(b) Date employee removed from payroll, bi-weekly or either the 15th or the end of month: _____ / _____ /__________

(c) Has employee returned to work? Yes No Date returned to work _____ / _____ /__________

4. Reason for removal: Resignation Medical Leave of Absence Discharge/Dismissal Service Connected Leave Layoff Death (Was member on an approved medical leave of absence at death? Yes No)

5. Total unused sick days earned prior to January 1, 1984 .................................................. __________Total unused sick days earned after December 31, 1997 ................................................. __________Total unused sick days earned after December 31, 1983 and before January 1, 1998 .................................................................. ....................__________Less: One-half of unused sick days earned after December 31, 1983 and before January 1, 1998 .................................................................... .....................(__________) __________Number of unused sick days remaining for pension calculation ........................................A + B + C = __________

6. (a) Employee base rate of pay: $ ___________________; (b) Employee work status: Full-Time Part-Time (c) Employee total rate of pay: $____________________; (d) Frequency of pay: monthly semi-monthly bi-weekly hourly

7. Will a Form 1404 (Retirement Contributions on Lump Sum Pay for Sick Leave, Vacation, and/or Personal Days) be processed? Yes No

COMPLETE 8 AND 9 FOR DISABILITY CLAIMS ONLY

8. Has the employee filed a claim for Worker's Compensation benefits? Yes No

9. (a) Is there any indication that this is a work-related disability? Yes No (b) If yes, was a 3rd party involved ? Yes No

Retirement Coordinator's Signature ______________________________________________________________

Date ________________________ Phone Number ____________________________ Extension Number__________

3900 (R-10-14) IL 589-0108 (See reverse side for instructions)

AB

C

Month Day Year




Effective date of Action_____ / _____ /__________

Month Day Year

Month Day Year

Month Day Year

Month Day Year

68 srs.illinois.gov

JOB DUTY STATEMENT

Employee Name Soc. Sec. No.

Address Job Title

Please indicate, by using the letter A through G in the grading system below, the average daily job demand of the above named employee. If lifting isinvolved please indicate if the employee must also carry the object. Also, indicate if the employee would have intermittent rest while performing the demand.TO BE COMPLETED BY EMPLOYEE'S SUPERVISOR.

GRADING SYSTEM

A - (6-8 hrs per day) C - (2-4 hrs per day) E - (less than 3 times per week) G - Never B - (4-6 hrs per day) D - (0-2 hrs per day) F - (less than 3 times per month)

DEMANDS OF THE JOB

1 ___ Working on or with moving machinery ( with without intermittent rest) 2 ___ Working on or with moving machinery using foot controls ( with without intermittent rest) 3 ___ Driving automotive equipment - including loading & unloading ( with without intermittent rest) 4 ___ Driving automotive equipment - ( with without intermittent rest) 5 ___ Lifting 1-10 lbs ( with without carrying) ( with without intermittent rest) (is help available yes no) 6 ___ Lifting 11-25 lbs ( with without carrying) ( with without intermittent rest) (is help available yes no) 7 ___ Lifting 26-50 lbs ( with without carrying) ( with without intermittent rest) (is help available yes no) 8 ___ Lifting 51-100 lbs ( with without carrying) ( with without intermittent rest) (is help available yes no) 9 ___ Pushing and hand trucking (weight ) (number of times per day ) ( with without intermittent rest) 10 ___ Climbing stairs - ( with without intermittent rest)11 ___ Climbing ladders - ( with without intermittent rest)12 ___ Walking - ( with without intermittent rest)13 ___ Standing - ( with without intermittent rest)14 ___ Sitting15 ___ Running16 ___ Bending or stooping - ( with without intermittent rest) 17 ___ Reaching above shoulder level - ( with without intermittent rest)18 ___ Use of hands for gross manipulation (grasping, twisting, handling)19 ___ Use of hands for fine manipulation (typing, good finger dexterity)20 ___ Wet work - hands21 ___ Wet work - feet22 ___ Dust, fumes, gases-respiratory irritants23 ___ Dust, fumes, gases-skin irritants24 ___ Dust, fumes, gases-allergic irritants25 ___ Use of a weapon26 ___ Dealing with combative individuals27 ___ Other / comments (use back of form if necessary to describe any job demands unique to this employee's duties)

Date , 20 Signature of Supervisor Name of Agency Phone Address Street and Number City or Town State Zip Code

3935 (R-2-07) IL 589-013

(needs to be regular job title not temporary title)

Please complete Section below based on actual job duties employee is required to perform

JOB DUTY STATEMENT

Employee Name Soc. Sec. No.

Address Job Title

Please indicate, by using the letter A through G in the grading system below, the average daily job demand of the above named employee. If lifting isinvolved please indicate if the employee must also carry the object. Also, indicate if the employee would have intermittent rest while performing the demand.TO BE COMPLETED BY EMPLOYEE'S SUPERVISOR.

GRADING SYSTEM

A - (6-8 hrs per day) C - (2-4 hrs per day) E - (less than 3 times per week) G - Never B - (4-6 hrs per day) D - (0-2 hrs per day) F - (less than 3 times per month)

DEMANDS OF THE JOB

1 ___ Working on or with moving machinery ( with without intermittent rest) 2 ___ Working on or with moving machinery using foot controls ( with without intermittent rest) 3 ___ Driving automotive equipment - including loading & unloading ( with without intermittent rest) 4 ___ Driving automotive equipment - ( with without intermittent rest) 5 ___ Lifting 1-10 lbs ( with without carrying) ( with without intermittent rest) (is help available yes no) 6 ___ Lifting 11-25 lbs ( with without carrying) ( with without intermittent rest) (is help available yes no) 7 ___ Lifting 26-50 lbs ( with without carrying) ( with without intermittent rest) (is help available yes no) 8 ___ Lifting 51-100 lbs ( with without carrying) ( with without intermittent rest) (is help available yes no) 9 ___ Pushing and hand trucking (weight ) (number of times per day ) ( with without intermittent rest) 10 ___ Climbing stairs - ( with without intermittent rest)11 ___ Climbing ladders - ( with without intermittent rest)12 ___ Walking - ( with without intermittent rest)13 ___ Standing - ( with without intermittent rest)14 ___ Sitting15 ___ Running16 ___ Bending or stooping - ( with without intermittent rest) 17 ___ Reaching above shoulder level - ( with without intermittent rest)18 ___ Use of hands for gross manipulation (grasping, twisting, handling)19 ___ Use of hands for fine manipulation (typing, good finger dexterity)20 ___ Wet work - hands21 ___ Wet work - feet22 ___ Dust, fumes, gases-respiratory irritants23 ___ Dust, fumes, gases-skin irritants24 ___ Dust, fumes, gases-allergic irritants25 ___ Use of a weapon26 ___ Dealing with combative individuals27 ___ Other / comments (use back of form if necessary to describe any job demands unique to this employee's duties)

Date , 20 Signature of Supervisor Name of Agency Phone Address Street and Number City or Town State Zip Code

3935 (R-2-07) IL 589-013

(needs to be regular job title not temporary title)

Please complete Section below based on actual job duties employee is required to perform







srs.illinois.gov 69

(Enter numberof allowances.)

16. Have you ever been a member of the State Universities Retirement System of Illinois? YES NO

17. Have you ever been a member of the Teachers' Retirement System of Illinois? YES NO

18.Non-occupationaldisabilitybenefitsandtemporarydisabilitybenefitsaresubjecttofederalincometaxwithholdinginaccor-dancewithFederalWithholdingTables,unlessyouelectnottohavetaxeswithheld.ThesebenefitsareexemptfromIllinoisincometax.Aspartoftheapplicationprocessforthesebenefitsyouneedtocompletetheincometaxwithholdingthatap-pearsbelow.

Youmayelectnottohavewithholdingtaken,ortohavewithholdingtakenatanylevel.Ifyoudonotindicateapreferenceforwithholding,StateEmployees’RetirementSystem(SERS)mustwithholdattherateforamarriedpersonwiththreeexemp-tions.Youmaychangeyourwithholdingordiscontinuewithholdingatanytime.

1) Ielectnottohaveincometaxwithheldfrommydisabilitybenefit.(Donotcompleteline2or3.) ...............................

2) Iwantmywithholdingfromeachperiodicdisabilitypaymenttobefiguredusingthenumberofallowances

andmaritalstatusshown.(Youmayalsodesignateanadditionaldollaramountonline3.) ...................................... _____________

MaritalStatus:SingleMarriedMarried,butwithholdathigherSinglerate

3) Iwantthefollowingadditionalamountwithheldfromeachdisabilitypayment.Note:Forperiodicpayments,

youcannotenteranamountherewithoutenteringthenumber(includingzero)ofallowancesonline2..................... $_____________

19. IauthorizeSERStohavearepresentativereviewmyfileforthepurposeofevaluatingtheeligibilityofqualifyingfordisabilitybenefitsfromtheSocialSecurityAdministration(SSA),andwhicharepresentativemaycontactmeconcerningthefilingofsuchaclaim.IfIamreceivingdisabilitybenefitsorIameligibleforaretirementannuityfromSSA,IunderstandthatSERSmayoffsetthatamountfrommySERSbenefit.If I receive a SSA retroactive disability award, this will create an over payment of SERS disability benefits which I will have to pay back to SERS. I will contact SERS as soon as I receive either benefit from SSA.

20. Ialsoauthorizetheexchangeofinformationwithphysiciansperformingindependentmedicalconsultations.IalsoagreetopermittheSERStofurnishmedicaldocumentationtotheappropriateagencyforthepurposeofdocumentingmyleavestatus.

21. IherebycertifythatIhavenotbeengainfullyemployedduringthetimeIamclaimingdisability.IwillnotifytheSERSimmedi-atelywhenmydisabilityceases;orwhenIreturntostateemployment;orwhenIacceptothergainfulemployment.IauthorizeSERStoapplyanyfuturedisabilitybenefits,pensionbenefits,deathbenefitsorrefundofcontributionstoanyexcessdisabilitybenefitImayhavereceiveduntiltheexcessdisabilitybenefitisrepaidinfull.

22. Icertifythisinformationiscorrect.Iamawarethatpursuanttothe40ILCS5/1-135anypersonwhoknowinglymakesafalsestatementorfalsifiesarecordinanattempttodefraudtheStateEmployees’RetirementSystemisguiltyofaClass3felony.IftheSERSBoardofTrusteeshasareasonablesuspicionthatanattempthasbeenmadetodefraudSERS,itisrequiredtoreportthemattertotheappropriatestate’sattorneyforinvestigation.

___________________________________________________ Signature Date

Federal Income Tax Withholding for Disability Payments

APPLICATION FOR NON-OCCUPATIONAL DISABILITY BENEFITS

Complete the following if there is no label or the label is incorrect!

Social Security Number

FirstName Middle Last

StreetAddress(PermanentMailingAddress)

City State ZipCode

1. TelephoneNumber:(home)________________________(work)________________________

2.EmailAddress____________________________________________________________________________________

3. Titleofyourposition__________________________

4. Dateyourdisabilitybegan__________________________ 5.Dateyouceasedwork___________________________

6. Haveyoubeengrantedamedicalleaveofabsence?YESNO

7. Haveyoureturnedtowork?YESNO

8. Dateyoureturnedtowork__________________________ 9.Dateyouexpecttoreturntowork___________________

10.Describeaccidentorillnessthatcauseddisability:_________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

11.HaveyouappliedforaSocialSecurityBenefit?YESNO

12.AreyoucurrentlyreceivingaSocialSecurityBenefit?YESNOIfyesindicatebenefittype__________________

13.Name and complete address of physicians who have treated you for this disability: __________________________

_____________________________________________________________________________________________________

14.Nameandaddressofhospitaltowhichyouwereconfinedforthisdisability:____________________________________

_____________________________________________________________________________________________________

15.Datesyouwereconfinedtohospital,from:______________________________to________________________

3924_non (R-7-15) - OVER -




70 srs.illinois.gov




18.Non-occupationaldisabilitybenefitsandtemporarydisabilitybenefitsaresubjecttofederalincometaxwithholdinginaccor-dancewithFederalWithholdingTables,unlessyouelectnottohavetaxeswithheld.ThesebenefitsareexemptfromIllinoisincometax.Aspartoftheapplicationprocessforthesebenefitsyouneedtocompletetheincometaxwithholdingthatap-pearsbelow.

Youmayelectnottohavewithholdingtaken,ortohavewithholdingtakenatanylevel.Ifyoudonotindicateapreferenceforwithholding,StateEmployees’RetirementSystem(SERS)mustwithholdattherateforamarriedpersonwiththreeexemp-tions.Youmaychangeyourwithholdingordiscontinuewithholdingatanytime.

1) Ielectnottohaveincometaxwithheldfrommydisabilitybenefit.(Donotcompleteline2or3.) ...............................

2) Iwantmywithholdingfromeachperiodicdisabilitypaymenttobefiguredusingthenumberofallowances

andmaritalstatusshown.(Youmayalsodesignateanadditionaldollaramountonline3.) ...................................... _____________

MaritalStatus:SingleMarriedMarried,butwithholdathigherSinglerate

3) Iwantthefollowingadditionalamountwithheldfromeachdisabilitypayment.Note:Forperiodicpayments,

youcannotenteranamountherewithoutenteringthenumber(includingzero)ofallowancesonline2..................... $_____________

19. IauthorizeSERStohavearepresentativereviewmyfileforthepurposeofevaluatingtheeligibilityofqualifyingfordisabilitybenefitsfromtheSocialSecurityAdministration(SSA),andwhicharepresentativemaycontactmeconcerningthefilingofsuchaclaim.IfIamreceivingdisabilitybenefitsorIameligibleforaretirementannuityfromSSA,IunderstandthatSERSmayoffsetthatamountfrommySERSbenefit.If I receive a SSA retroactive disability award, this will create an over payment of SERS disability benefits which I will have to pay back to SERS. I will contact SERS as soon as I receive either benefit from SSA.

20. Ialsoauthorizetheexchangeofinformationwithphysiciansperformingindependentmedicalconsultations.IalsoagreetopermittheSERStofurnishmedicaldocumentationtotheappropriateagencyforthepurposeofdocumentingmyleavestatus.

21. IherebycertifythatIhavenotbeengainfullyemployedduringthetimeIamclaimingdisability.IwillnotifytheSERSimmedi-atelywhenmydisabilityceases;orwhenIreturntostateemployment;orwhenIacceptothergainfulemployment.IauthorizeSERStoapplyanyfuturedisabilitybenefits,pensionbenefits,deathbenefitsorrefundofcontributionstoanyexcessdisabilitybenefitImayhavereceiveduntiltheexcessdisabilitybenefitisrepaidinfull.

22. Icertifythisinformationiscorrect.Iamawarethatpursuanttothe40ILCS5/1-135anypersonwhoknowinglymakesafalsestatementorfalsifiesarecordinanattempttodefraudtheStateEmployees’RetirementSystemisguiltyofaClass3felony.IftheSERSBoardofTrusteeshasareasonablesuspicionthatanattempthasbeenmadetodefraudSERS,itisrequiredtoreportthemattertotheappropriatestate’sattorneyforinvestigation.

___________________________________________________ Signature Date


APPLICATION FOR NON-OCCUPATIONAL DISABILITY BENEFITS



FirstName Middle Last

StreetAddress(PermanentMailingAddress)

City State ZipCode

1. TelephoneNumber:(home)________________________(work)________________________

2.EmailAddress____________________________________________________________________________________

3. Titleofyourposition__________________________

4. Dateyourdisabilitybegan__________________________ 5.Dateyouceasedwork___________________________

6. Haveyoubeengrantedamedicalleaveofabsence?YESNO

7. Haveyoureturnedtowork?YESNO

8. Dateyoureturnedtowork__________________________ 9.Dateyouexpecttoreturntowork___________________

10.Describeaccidentorillnessthatcauseddisability:_________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

11.HaveyouappliedforaSocialSecurityBenefit?YESNO

12.AreyoucurrentlyreceivingaSocialSecurityBenefit?YESNOIfyesindicatebenefittype__________________

13.Name and complete address of physicians who have treated you for this disability: __________________________

_____________________________________________________________________________________________________

14.Nameandaddressofhospitaltowhichyouwereconfinedforthisdisability:____________________________________

_____________________________________________________________________________________________________

15.Datesyouwereconfinedtohospital,from:______________________________to________________________

3924_non (R-7-15) - OVER -




srs.illinois.gov 71

15. Name and address of hospital to which you were confined for this disability: __________________________________

___________________________________________________________________________________________________

16. Dates you were confined to hospital, from: ______________________________ to________________________



19. Occupational disability benefits paid by SERS are exempt from federal and Illinois income tax. Although exempt, these benefits are reportable and a 1099-R form will be issued each January.

20. I hereby certify that I have not been gainfully employed during the time I am claiming disability. I will notify the State Em-ployees' Retirement System immediately when my disability ceases; or when I return to state employment; or when I accept other gainful employment.

21. I also agree that if this disability is for occupational reasons, I authorize the State Employees' Retirement System to ex-change information with the appropriate agency handling workers' compensation relative to my claim and with physicians performing independent medical consultations. Further, I authorize the State Employees' Retirement System to have an agent or representative review my file for the purpose of evaluating the likelihood of my qualifying for social security dis-ability benefits, which agent or representative may contact me concerning the filing of such a claim. I also agree to permit the State Employees' Retirement System to furnish medical documentation to the Department of Personnel for the purpose of documenting my leave status.

22. In the event that my injury was caused by a third party and a lawsuit is filed (and I collect an award from that party), I un-derstand that the State Employees’ Retirement System is entitled to be reimbursed for sums paid to me in Occupational Disability Benefits and service contributions.

23. I authorize the State Employees’ Retirement System to apply any future disability benefits, pension benefits, death benefits or refund of contributions to any excess disability benefit I may have received until the excess disability benefit is repaid in full.

24. I certify this information is correct. I am aware that pursuant to the 40 ILCS 5/1-135 any person who knowingly makes a false statement or falsifies a record in an attempt to defraud the State Employees’ Retirement System is guilty of a Class 3 felony. If the SERS Board of Trustees has a reasonable suspicion that an attempt has been made to defraud SERS, it is required to report the matter to the appropriate state’s attorney for investigation.

___________________________________________________ Signature Date

Note: If this application is not returned within 12 months from the date you were removed from the payroll, itcouldresultinalossofbenefits.

APPLICATION FOR OCCUPATIONAL DISABILITY BENEFITS



First Name Middle Last

Street Address (Permanent Mailing Address)

City State Zip Code

You are required to submit a copy of the Workers’ Compensation Employees’ Notice of Injury (CMS 900) with this application for Occupational Disability Benefits.

1. Telephone Number: (home)____________________ (work)_____________________ (mobile)____________________

2. Email Address ___________________________________________________________________________________

3. Title of your position __________________________

4. What is the status of your claim for Workers’ Compensation Benefits? Approved Denied No Decision

5. Date of injury or accident __________________________ 6. Date you ceased work ___________________________

7. Have you been removed from your agency payroll ? YES NO

8. Have you returned to work? YES NO

9. Date you returned to work __________________________ 10. Date you expect to return to work __________________

11. Did a third party (other than your employer) cause this accident? YES NO

12. If you answered yes to #11, is a lawsuit being filed against that party? YES NO

13. Describe accident or illness that caused disability: _________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

14. Name and complete address of physicians who have treated you for this disability: __________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

3924_Occ (R-4-16) - OVER -




72 srs.illinois.gov

15. Name and address of hospital to which you were confined for this disability: __________________________________

___________________________________________________________________________________________________




19. Occupational disability benefits paid by SERS are exempt from federal and Illinois income tax. Although exempt, these benefits are reportable and a 1099-R form will be issued each January.

20. I hereby certify that I have not been gainfully employed during the time I am claiming disability. I will notify the State Em-ployees' Retirement System immediately when my disability ceases; or when I return to state employment; or when I accept other gainful employment.

21. I also agree that if this disability is for occupational reasons, I authorize the State Employees' Retirement System to ex-change information with the appropriate agency handling workers' compensation relative to my claim and with physicians performing independent medical consultations. Further, I authorize the State Employees' Retirement System to have an agent or representative review my file for the purpose of evaluating the likelihood of my qualifying for social security dis-ability benefits, which agent or representative may contact me concerning the filing of such a claim. I also agree to permit the State Employees' Retirement System to furnish medical documentation to the Department of Personnel for the purpose of documenting my leave status.

22. In the event that my injury was caused by a third party and a lawsuit is filed (and I collect an award from that party), I un-derstand that the State Employees’ Retirement System is entitled to be reimbursed for sums paid to me in Occupational Disability Benefits and service contributions.

23. I authorize the State Employees’ Retirement System to apply any future disability benefits, pension benefits, death benefits or refund of contributions to any excess disability benefit I may have received until the excess disability benefit is repaid in full.


___________________________________________________ Signature Date

Note: If this application is not returned within 12 months from the date you were removed from the payroll, itcouldresultinalossofbenefits.

APPLICATION FOR OCCUPATIONAL DISABILITY BENEFITS





City State Zip Code

You are required to submit a copy of the Workers’ Compensation Employees’ Notice of Injury (CMS 900) with this application for Occupational Disability Benefits.

1. Telephone Number: (home)____________________ (work)_____________________ (mobile)____________________

2. Email Address ___________________________________________________________________________________


4. What is the status of your claim for Workers’ Compensation Benefits? Approved Denied No Decision








_____________________________________________________________________________________________________

_____________________________________________________________________________________________________


_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

3924_Occ (R-4-16) - OVER -




srs.illinois.gov 73

APPLICATION FOR TEMPORARY DISABILITY BENEFITS





City State Zip Code

You are required to submit a copy of the Workers’ Compensation Employees’ Notice of Injury (CMS900) with this application for Temporary Disability Benefits.

1. Telephone Number: (home)________________________(work)________________________


3. Was this disability work related? (If yes, you must file for Workers Compensation benefits) YES NO

4. Have you filed a claim for Workers' Compensation for this disability? YES NO

5. Has Workers’ Compensation denied your request or terminated your benefit.








_____________________________________________________________________________________________________

15. Have you applied for any type of Social Security Benefit? YES NO

16 Are you currently receiving a Social Security Benefit? YES NO If yes indicate benefit type ___________________


_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

3924_T (R-4-16) - OVER -


18. Name and address of hospital to which you were confined for this disability: ____________________________________

_____________________________________________________________________________________________________




22. Temporary disability benefit is subject to federal income tax withholding in accordance with Federal Withholding Tables, unless you elect not to have taxes withheld. These benefits are exempt from Illinois income tax. As part of the application process for these benefits you need to complete the income tax withholding that appears below.

You may elect not to have withholding taken, or to have withholding taken at any level. If you do not indicate a preference for withholding, SERS must withhold at the rate for a married person with three exemptions. You may change your withholding or discontinue withholding at any time.

Occupational disability benefits paid by SERS are exempt from federal and Illinois income tax. Although exempt, these ben-efits are reportable and a 1099-R form will be issued each January. If you are requesting occupational disability benefits you do not need to complete the withholding form that appears below.

1) I elect not to have income tax withheld from my disability benefit. (Do not complete line 2 or 3.) ...............................

2) I want my withholding from each periodic disability payment to be figured using the number of allowances

and marital status shown. (You may also designate an additional dollar amount on line 3.) ...................................... _____________

Marital Status: Single Married Married, but withhold at higher Single rate

3) I want the following additional amount withheld from each disability payment. Note: For periodic payments,

you cannot enter an amount here without entering the number (including zero) of allowances on line 2..................... $_____________

23. I hereby certify that I have not been gainfully employed during the time I am claiming disability. I will notify the State Employees’ Retirement System immediately when my disability ceases; or when I return to state employment; or when I accept other gain-ful employment. I authorize the State Employees’ Retirement System to apply any future disability benefits, pension benefits, death benefits or refund of contributions to any excess disability benefit I may have received until the excess disability benefit is repaid in full. I also agree that if this disability is for occupational reasons, I authorize the State Employees’ Retirement System to exchange information with the appropriate agency handling workers’ compensation relative to my claim and with physicians performing independent medical consultations. Further, I authorize the State Employees’ Retirement System to have an agent or representative review my file for the purpose of evaluating the likelihood of my qualifying for social security disability benefits, which agent or representative may contact me concerning the filing of such a claim. I also agree to permit the State Employees’ Retirement System to furnish medical documentation to the Department of Personnel for the purpose of documenting my leave status. In the event that my injury was caused by a third party and a lawsuit is filed (and I collect an award from that party), I understand that the State Employees’ Retirement System is entitled to be reimbursed for sums paid to me in Temporary Disability Benefits and service contributions.


___________________________________________________ Signature Date

Note: If this application is not returned within the 12 months from the date you were removed from the payroll, itcouldresultinalossofbenefits.





74 srs.illinois.gov

APPLICATION FOR TEMPORARY DISABILITY BENEFITS





City State Zip Code

You are required to submit a copy of the Workers’ Compensation Employees’ Notice of Injury (CMS900) with this application for Temporary Disability Benefits.

1. Telephone Number: (home)________________________(work)________________________


3. Was this disability work related? (If yes, you must file for Workers Compensation benefits) YES NO

4. Have you filed a claim for Workers' Compensation for this disability? YES NO

5. Has Workers’ Compensation denied your request or terminated your benefit.








_____________________________________________________________________________________________________

15. Have you applied for any type of Social Security Benefit? YES NO

16 Are you currently receiving a Social Security Benefit? YES NO If yes indicate benefit type ___________________


_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

3924_T (R-4-16) - OVER -


18. Name and address of hospital to which you were confined for this disability: ____________________________________

_____________________________________________________________________________________________________




22. Temporary disability benefit is subject to federal income tax withholding in accordance with Federal Withholding Tables, unless you elect not to have taxes withheld. These benefits are exempt from Illinois income tax. As part of the application process for these benefits you need to complete the income tax withholding that appears below.

You may elect not to have withholding taken, or to have withholding taken at any level. If you do not indicate a preference for withholding, SERS must withhold at the rate for a married person with three exemptions. You may change your withholding or discontinue withholding at any time.

Occupational disability benefits paid by SERS are exempt from federal and Illinois income tax. Although exempt, these ben-efits are reportable and a 1099-R form will be issued each January. If you are requesting occupational disability benefits you do not need to complete the withholding form that appears below.

1) I elect not to have income tax withheld from my disability benefit. (Do not complete line 2 or 3.) ...............................

2) I want my withholding from each periodic disability payment to be figured using the number of allowances

and marital status shown. (You may also designate an additional dollar amount on line 3.) ...................................... _____________

Marital Status: Single Married Married, but withhold at higher Single rate

3) I want the following additional amount withheld from each disability payment. Note: For periodic payments,

you cannot enter an amount here without entering the number (including zero) of allowances on line 2..................... $_____________

23. I hereby certify that I have not been gainfully employed during the time I am claiming disability. I will notify the State Employees’ Retirement System immediately when my disability ceases; or when I return to state employment; or when I accept other gain-ful employment. I authorize the State Employees’ Retirement System to apply any future disability benefits, pension benefits, death benefits or refund of contributions to any excess disability benefit I may have received until the excess disability benefit is repaid in full. I also agree that if this disability is for occupational reasons, I authorize the State Employees’ Retirement System to exchange information with the appropriate agency handling workers’ compensation relative to my claim and with physicians performing independent medical consultations. Further, I authorize the State Employees’ Retirement System to have an agent or representative review my file for the purpose of evaluating the likelihood of my qualifying for social security disability benefits, which agent or representative may contact me concerning the filing of such a claim. I also agree to permit the State Employees’ Retirement System to furnish medical documentation to the Department of Personnel for the purpose of documenting my leave status. In the event that my injury was caused by a third party and a lawsuit is filed (and I collect an award from that party), I understand that the State Employees’ Retirement System is entitled to be reimbursed for sums paid to me in Temporary Disability Benefits and service contributions.


___________________________________________________ Signature Date

Note: If this application is not returned within the 12 months from the date you were removed from the payroll, itcouldresultinalossofbenefits.





srs.illinois.gov 75 Printed on recycled paper

RELEASE OF INFORMATION AUTHORIZATION

I authorize any physician, hospital, insurer, the Social Security Administration or another organization having any records, data or information concerning me to furnish such records, data or information to the State Employees’ Retirement System of Illinois.

The type of information to be disclosed includes the patient’s entire medical record, employment record (including salary postings), or a record of all benefit payments.

I understand that the information being disclosed may include information relating to sexually transmitted disease, acquire immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, treatment for alcohol and drug abuse and generic health information from medical records.

The information for which I am authorizing disclosure will be used for establishing eligibility for disabil-ity benefits from the State Employees’ Retirement System.

I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing. I understand that the revocation will not apply to information that has already been released in response to this authorization.

This authorization will expire 12 months from the date of signature listed below, unless otherwise re-voked.

I understand that once the above information is received, it may be disclosed by the recipient pursuant to evaluating my continued eligibility for disability benefits, and may no longer be protected by federal privacy regulations. The State Employees' Retirement System is not liable for any consequences of such re-disclosure.

I understand that authorizing the use or disclosure of the information identified is mandatory to establish my eligibility for disability benefits.

State Employees' Retirement

System of Illinois

(217)785-7444

TTY (217)785-7218

Accounting (217)785-7191

Admin. Services (217)785-6971

Deaths(217)785-7366

Deaths Fax(217) 524-2293

Disabilities

(217)785-7318

Disabilities Fax(217) 785-6961

Group Insurance

(217)785-7150

Group Ins. Fax(217) 557-0510

Pensions

(217)785-7343

Pensions Fax(217) 524-2293

Vouchering

(217)785-7034

Vouchering Fax(217) 557-0510

Data Processing (217)785-6957

Exec. Offices(217)785-7016

Exec. Office Fax (217)557-3943

Gen. Info. Fax (217)785-7019

Field Services (217)785-6979

Field Serv. Fax(217)557-5154

Refunds (217)785-7187

Service (217)785-7167

Service & Refunds Fax

(217)785-6964

Chicago Office (312)814-5853

Chicago Fax (312)814-5805

Judges'Retirement System of

Illinois(217)782-8500

General Assembly Retirement

System (217)782-8500

Name:

Address:

City: State: Zip:

Phone: Email:

Social Security Number: Date of Birth:

Signature: Date of Signature:

Witness: Date of Signature:

( Please Print)

3934 (R-12-15)




ANY PERSON WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE OR MISLEADING INFOR-MATION TO THE STATE EMPLOYEES’ RETIREMENT SYSTEM IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES, DENIAL OF BENEFITS AND CONFINEMENT IN A STATE PRISON.

Printed on recycled paper

RELEASE OF INFORMATION AUTHORIZATION

I authorize any physician, hospital, insurer, the Social Security Administration or another organization having any records, data or information concerning me to furnish such records, data or information to the State Employees’ Retirement System of Illinois.

The type of information to be disclosed includes the patient’s entire medical record, employment record (including salary postings), or a record of all benefit payments.

I understand that the information being disclosed may include information relating to sexually transmitted disease, acquire immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, treatment for alcohol and drug abuse and generic health information from medical records.

The information for which I am authorizing disclosure will be used for establishing eligibility for disabil-ity benefits from the State Employees’ Retirement System.

I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing. I understand that the revocation will not apply to information that has already been released in response to this authorization.

This authorization will expire 12 months from the date of signature listed below, unless otherwise re-voked.

I understand that once the above information is received, it may be disclosed by the recipient pursuant to evaluating my continued eligibility for disability benefits, and may no longer be protected by federal privacy regulations. The State Employees' Retirement System is not liable for any consequences of such re-disclosure.

I understand that authorizing the use or disclosure of the information identified is mandatory to establish my eligibility for disability benefits.

State Employees' Retirement

System of Illinois

(217)785-7444

TTY (217)785-7218

Accounting (217)785-7191

Admin. Services (217)785-6971

Deaths(217)785-7366

Deaths Fax(217) 524-2293

Disabilities

(217)785-7318

Disabilities Fax(217) 785-6961

Group Insurance

(217)785-7150

Group Ins. Fax(217) 557-0510

Pensions

(217)785-7343

Pensions Fax(217) 524-2293

Vouchering

(217)785-7034

Vouchering Fax(217) 557-0510

Data Processing (217)785-6957

Exec. Offices(217)785-7016

Exec. Office Fax (217)557-3943

Gen. Info. Fax (217)785-7019

Field Services (217)785-6979

Field Serv. Fax(217)557-5154

Refunds (217)785-7187

Service (217)785-7167

Service & Refunds Fax

(217)785-6964

Chicago Office (312)814-5853

Chicago Fax (312)814-5805

Judges'Retirement System of

Illinois(217)782-8500

General Assembly Retirement

System (217)782-8500

Name:

Address:

City: State: Zip:

Phone: Email:

Social Security Number: Date of Birth:

Signature: Date of Signature:

Witness: Date of Signature:

( Please Print)

3934 (R-12-15)




ANY PERSON WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE OR MISLEADING INFOR-MATION TO THE STATE EMPLOYEES’ RETIREMENT SYSTEM IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES, DENIAL OF BENEFITS AND CONFINEMENT IN A STATE PRISON.

(Anyone over the age of 18) (Anyone over the age of 18)

76 srs.illinois.gov

NON-OCCUPATIONAL DISABILITY MEDICAL REPORTDear Doctor:

The employee named below has made application for disability benefits from the State Employees' Retirement System. Please complete and return this form to the above address or fax to (217) 785-6961. The employee’s eligibility for benefits cannot be determined until we receive this information. This form is acceptable only if completed by a licensed medical doctor.

DIAGNOSIS AND CONCURRENT CONDITIONS: _______________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

CURRENT SYMPTOMS:____________________________________________________________________________

_________________________________________________________________________________________________

PREGNANCY (Expected Delivery Date): _____________________________________________

PLEASE LIST RESULTS OF APPROPRIATE DIAGNOSTIC STUDIES: ____________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

NATURE OF TREATMENT AND DATES: (Enclose a copy of your office records if more convenient)____________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

ONSET DATE OF DISABILITY___________________________

IS PATIENT STILL UNDER YOUR CARE FOR THE DIAGNOSIS LISTED ABOVE? YES NO

IF PATIENT HAS BEEN RELEASED TO RETURN TO WORK:____________________________________________

REMARKS: ______________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

THE ABOVE NAMED INDIVIDUAL APPEARED BEFORE ME FOR MEDICAL EXAMINATION.THE DIAGNOSIS, TREATMENT AND REMARKS ARE MY PROFESSIONAL OPINION.

PRINTED NAME:__________________________________

SIGNATURE: ____________________________________ DATE: ______________________________________

ADDRESS: ____________________________________ SPECIALTY: _________________________________

____________________________________ TELEPHONE NUMBER: _______________________

3114 (R-4-12) IL 589-0061

(Please enter date released)

Employee Name:

S.S.N.

Date of Birth




NON-OCCUPATIONAL DISABILITY MEDICAL REPORTDear Doctor:

The employee named below has made application for disability benefits from the State Employees' Retirement System. Please complete and return this form to the above address or fax to (217) 785-6961. The employee’s eligibility for benefits cannot be determined until we receive this information. This form is acceptable only if completed by a licensed medical doctor.

DIAGNOSIS AND CONCURRENT CONDITIONS: _______________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

CURRENT SYMPTOMS:____________________________________________________________________________

_________________________________________________________________________________________________

PREGNANCY (Expected Delivery Date): _____________________________________________

PLEASE LIST RESULTS OF APPROPRIATE DIAGNOSTIC STUDIES: ____________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

NATURE OF TREATMENT AND DATES: (Enclose a copy of your office records if more convenient)____________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

ONSET DATE OF DISABILITY___________________________

IS PATIENT STILL UNDER YOUR CARE FOR THE DIAGNOSIS LISTED ABOVE? YES NO

IF PATIENT HAS BEEN RELEASED TO RETURN TO WORK:____________________________________________

REMARKS: ______________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________


PRINTED NAME:__________________________________

SIGNATURE: ____________________________________ DATE: ______________________________________

ADDRESS: ____________________________________ SPECIALTY: _________________________________

____________________________________ TELEPHONE NUMBER: _______________________

3114 (R-4-12) IL 589-0061

(Please enter date released)

Employee Name:

S.S.N.

Date of Birth




srs.illinois.gov 77

OCCUPATIONAL DISABILITY MEDICAL REPORT

DEAR DOCTOR:

The employee named below has made application for disability benefits from the State Employees' Retirement Sys-tem. Please complete and return this form to the above address or fax to 217-785-6961. The employee's eligibility for benefits cannot be determined until we receive this information. This form is acceptable only if completed by a licensed medical doctor.

DIAGNOSIS AND CONCURRENT CONDITIONS:

PLEASE LIST RESULTS OF APPROPRIATE LABORATORY STUDIES:

PLEASE LIST OBJECTIVE SYMPTOMS AND FINDINGS (Please be specific, i.e., B/P reading, or attach a copy of patient's charts):

NATURE OF TREATMENT AND DATES: (Enclose a copy of your office records if more convenient)

HOW LONG WAS OR WILL PATIENT BE CONTINUOUSLY MEDICALLY UNABLE TO WORK:ONSET DATE: , 20 TO: , 20RETURN TO WORK DATE: , 20

REMARKS:


PRINTED NAME: DATE:SIGNATURE: SPECIALTY:ADDRESS: TELEPHONE NUMBER: 3213 (R-4-12)

Employee Name:

S.S.N.

Date of Birth



2101 South Veterans Parkway, P.O. Box 19255, Springfield, IL 62794-9255Internet: http://www.srs.illinois.gov Email: [email protected]

OCCUPATIONAL DISABILITY MEDICAL REPORT

DEAR DOCTOR:

The employee named below has made application for disability benefits from the State Employees' Retirement Sys-tem. Please complete and return this form to the above address or fax to 217-785-6961. The employee's eligibility for benefits cannot be determined until we receive this information. This form is acceptable only if completed by a licensed medical doctor.

DIAGNOSIS AND CONCURRENT CONDITIONS:

PLEASE LIST RESULTS OF APPROPRIATE LABORATORY STUDIES:

PLEASE LIST OBJECTIVE SYMPTOMS AND FINDINGS (Please be specific, i.e., B/P reading, or attach a copy of patient's charts):

NATURE OF TREATMENT AND DATES: (Enclose a copy of your office records if more convenient)

HOW LONG WAS OR WILL PATIENT BE CONTINUOUSLY MEDICALLY UNABLE TO WORK:ONSET DATE: , 20 TO: , 20RETURN TO WORK DATE: , 20

REMARKS:


PRINTED NAME: DATE:SIGNATURE: SPECIALTY:ADDRESS: TELEPHONE NUMBER: 3213 (R-4-12)

Employee Name:

S.S.N.

Date of Birth



2101 South Veterans Parkway, P.O. Box 19255, Springfield, IL 62794-9255Internet: http://www.srs.illinois.gov Email: [email protected]

78 srs.illinois.gov

BIRTH CERTIFICATE




DEAR MEMBER:

WE NEED A COPY OF YOUR BIRTH CERTIFICATE TO COMPLETE YOURMEMBERSHIP RECORD. PLEASE WRITE THE LAST FOUR DIGITS OF YOUR SOCIAL SECURITY NUMBER ON YOUR BIRTH CERTIFICATE.

Any person making application for a retirement annuity, survivor's annuity, temporary disability, non-occupational or occupational disability benefit must submit as proof of birth date, a legal copy of their birth certificate or birth record issued by state/county of birth.

If you DO NOT have a copy of your birth certificate, it will be necessary that you obtain a copy from the state in which you were born.

If NO RECORD EXISTS, you must submit a signed affidavit certifying that no birth record exists. Upon submission by the signed affidavit, the following documents may be submitted for consideration of proof of birth date:

1) Military Records; 2) Marriage record showing date of birth; 3) Evidence of social Security payments that require attainment of specific age; 4) Church record of birth or baptism; 5) Valid Passport; 6) Valid driver’s license; or 7) Two or more documents showing birth dates, such as, Naturalization papers,

insurance policies, school records or medical records.

If none of the above documents are available, an affidavit from parents, older sibling, or relative having knowledge of the date of birth may be considered. If you need information on where to write for your birth record, please contact our office at (217)785-7444.

I am aware that pursuant to the 40 ILCS 5/1-135 any person who knowingly makes a false statement or falsifies a record in an attempt to defraud the State Employees’ Retirement System is guilty of a class 3 felony. If the SERS Board of Trustees has a reasonable suspicion that an attempt has been made to defraud SERS, it is required to report the matter to the appropriate state’s attorney for investigation.

3928 (R-10-17)

srs.illinois.gov 79

PART I (TO BE COMPLETED BY SERS MEMBERS)

I, (Name of SERS Member) (Social Security Number)

hereby authorize the Social Security Administration to furnish the information requested below to the STATE EMPLOYEES' RETIREMENT SYSTEM OF ILLINOIS. This information is required in the compu-tation of benefits payable to me by the State Employees' Retirement System.

(Signature of Claimant) (Street)

(Date) (City) (State) (Zip Code)

PART II (SOCIAL SECURITY ADMINISTRATION ONLY)

Please complete this form based on the worker's record for unreduced retirement benefits he/she would be eligible to receive on the date indicated below.

Unreduced Social Security Retirement Benefits as of would be .

Send information to:

STATE EMPLOYEES' RETIREMENT SYSTEM (Signature)

2101 South Veterans Parkway

P.O. Box 19255 (Title)

Springfield, Illinois 62794-9255 (District Office)

Date

3129 (R-10-10)

UNREDUCED SOCIAL SECURITY PENSION ESTIMATEOnly to be completed if you are currently age 65 or greater

PART I (TO BE COMPLETED BY SERS MEMBERS)

I, (Name of SERS Member) (Social Security Number)

hereby authorize the Social Security Administration to furnish the information requested below to the STATE EMPLOYEES' RETIREMENT SYSTEM OF ILLINOIS. This information is required in the compu-tation of benefits payable to me by the State Employees' Retirement System.

(Signature of Claimant) (Street)

(Date) (City) (State) (Zip Code)

PART II (SOCIAL SECURITY ADMINISTRATION ONLY)

Please complete this form based on the worker's record for unreduced retirement benefits he/she would be eligible to receive on the date indicated below.

Unreduced Social Security Retirement Benefits as of would be .

Send information to:

STATE EMPLOYEES' RETIREMENT SYSTEM (Signature)

2101 South Veterans Parkway

P.O. Box 19255 (Title)

Springfield, Illinois 62794-9255 (District Office)

Date

3129 (R-10-10)

UNREDUCED SOCIAL SECURITY PENSION ESTIMATEOnly to be completed if you are currently age 65 or greater







80 srs.illinois.gov

Pensions forms

RETIREMENT CONTRIBUTIONS ON LUMP SUM PAYFOR SICK LEAVE, VACATION, AND/OR PERSONAL DAYS

Any member of the State Employees' Retirement System who is paid a lump sum for sick leave, vacation, and/or personal days when resigning for the purpose of retiring, may make contributions to establish service credit for the number of days for which payment is made. Service credit will be granted for unused sick days for pension calculation purposes. Voluntary retirement contributions made for accumulated vacation, sickness or personal business must be made within 90 days of withdrawal at the compensation and retirement rates in effect at the time of retirement.

Part I: To be completed by Agency (please print or type this form)

From: Agency:________________________________________________________________________________________

Address:________________________________________________________________________________________ Member's Name:_________________________________________________________________________________

S.S. #:___________________________________________ Termination Date: ______________________________ Deduction Codes O/A 1/B R/K S/D 2/C M/B Payroll Code____________________

Part II: To be completed by Employee if PRE-TAX is elected (except line 1 which is to be completed by Agency).

PRE-TAX: (Contributions are not taxed until after employee retires.) I elect and authorize the deduction of employee retirement contributions from my lump sum pay for sick days, vacation and or personal days on a pre-tax (i.e. tax deferred) basis. If this option is selected, the employee must complete the "Irrevocable Payroll Authorization of Permissive Service Credits or Redeposit of Contributions" below.


A State Employees’ Retirement System (SERS) member, pursuant to statute, is permitted to redeposit member contributions previously withdrawn and/or elect to purchase permissive service credit. Any amounts due may generally be paid by the member directly to the retirement system, or the member may request, and the employer may permit, deductions through payroll. These payments through payroll deduction are in addition to any required contributions to SERS.

I understand that the State of Illinois (“my employer”) has adopted a statute under the “pickup” tax deferral provisions of Internal Revenue Code Section 414 (h) (2) for payroll deduction and that tax deferral of my purchase of permissive service requires this irrevocable payroll deduction authorization.

I hereby authorize and understand that this authorization is binding and irrevocable.

1. A deduction is to be made from my lump sum sick and vacation payment in the amount of $___________


3. Myemployerisobligatedtomakepaymentpursuanttothisagreementonlyiftherearesufficientfundsfrommyearningsto do so after any other mandatory deductions.


Employee Signature: _____________________________________________________ Date: _________________________

Part III: To be completed by Employee if POST-TAX is elected.

POST-TAX: (Contributions are taxed at the time of Lump Sum payment.) I elect and authorize the deduction of employee retirement contributions on my lump sum pay for sick days, vacation and/or personal days on a post-tax (i.e. NOT tax deferred) basis. If post-tax is elected, DO NOT complete Part II above.

Employee Signature: ___________________________________________________ Date: __________________________

1404 (R-10-10)

Line 1 is to be completed by Agency and MUST agree with amount on Page 2, Section IV.

ELECTION - Employee completes either Part II or Part III, NOT BOTH

(Street) (City) (State) (Zip)

srs.illinois.gov 81

A

USE THIS FORM FOR LUMP SUM PAYMENTS FOR SICK, VACATION AND/OR PERSONAL DAYS ONLYTHIS PAGE TO BE COMPLETED BY AGENCY

Member Name: ______________________________________________ Member SS#: ______________________

I. Calculation of unused sick days remaining for pension purposes. (Please be sure to use days, NOT hours.)

Total unused sick days earned prior to January 1, 1984 ......................................................... __________Total unused sick days earned after December 31, 1997 ........................................................ __________Total unused sick days earned after December 31, 1983 and before January 1, 1998 .................................................................. ....................__________Less: One-half of unused sick days earned after December 31, 1983 and before January 1, 1998 .......................................................................................(__________) __________Number of unused sick days remaining for pension calculation...............................................A + B + C = __________

Please enter the member's daily rate of pay ___________

II. Calculation of total sick, vacation and personal days to be paid to employee: (Please be sure to use days, NOT hours)

Payment is being made for: __________ Sick Days $ _______________ NOTE: Enter total dollar __________ Vacation Days $ _______________ amount 1 in __________ PersonalDays $_______________ Payfieldon Total Days $ Payroll Voucher

III. Calculation of sick, vacation and personal days to be used by employee to establish additional service credit less than the total amount above: (Use this section only if the employee is NOT going to purchase all service credit available in Step II above.) (Please be sure to use days, NOT hours.)

Service is being __________ Sick Days $ _______________ established for: __________ Vacation Days $ _______________ __________ Personal Days $ _______________ Total Days $

Note: If the employee has elected to tax defer his/her contributions, enter the contributions due in the miscellaneous de-ductionsfield,usingamiscellaneousdeductioncodeofBSLS.

If the employee has elected NOT to tax defer his/her contributions, enter the contributions due in the miscellaneous de-ductionsfield,usingamiscellaneousdeductioncodeof4SLS.

IV. Contributions Due Calculation of Contributions Due

Lump Sum Pay 1 or 2 as appropriate $__________ Deduction will be on:

X Deduction Rate (%) __________ Payroll Code _____________

= Contributions Due $ Pay Period _______________

V. Agency Certification Agency Name: _____________________________________________________ Preparer's Name (please print) : ________________________________________ Telephone Number _________________________ FAX____________________ Authorized Signature _________________________________________________ Telephone Number _________________________ FAX____________________

Please return completed form to:

B

C

1

2

Deduction Rate

4% 8%

8-1/2 % 12-1/2%

1404 (R-10-07) Page 2 of 2

STATE EMPLOYEES’ RETIREMENT OF ILLINOIS2101 South Veterans Parkway, P.O. Box 19255Springfield,IL62794-9255,Phone: 217/785-7210 Fax: 217/785-7019

Misc. Payroll Deduction Code ___________

82 srs.illinois.govPage 1 of 2

Member information

Name (Last, first, middle)Effective date of your retirement (MM/DD/YY)

/ 01 /Address (Street, City, State, Zip) Phone number

(H)SSN (last 4) Date of Birth (C)

Email address Birth Certificate requiredo Yes o No





SERS


srs.illinois.gov

Retirement ApplicationPlease print or type

217-785-7444Email: [email protected]

DependentsCurrent marital status (select one)

o Single, divorced, widowed o Married – Date of marriage or civil union: Month _________ Day _______ Year ________

If currently married, name of spouse: __________________________________________________

List all minor children, even if not living with you (including natural, adopted or step children) under age 18, under age 22 if a full-time student and/or over age 18 who are physically or mentally disabled. Dependent parents may be listed as well.Name Relationship Date of Birth Disabled

o Yes o Noo Yes o Noo Yes o Noo Yes o No

If you are single with no dependents or have been married less than one year, would you like a refund of survivor contributions?o Yes o NoIf you receive a refund of your survivor contributions, survivor benefits are not payable at the time of your death.

Legal historyWere you ever convicted of a felony related to, arising from or in connection with your service as a member of SERS?

o Yes o No

3004 (10/17)

srs.illinois.gov 83

Page 2 of 2

Social Security Offset removalAs part of your SERS benefits, your qualified survivor(s) will be eligible for a survivor annuity after yoru death. If you contributed to Social Security as a state employee, an offset of 50% is usually applied to the survivor benefit when the survivor becomes eligible for Social Security benefits. You may elect to reduce your retirement annuity by 3.825% to avoid the offset that may be applied to a future survivor annuity.

Please check one:o I elect to participate and authorize SERS to reduce my monthly benefit by 3.825%.o I do not elect to participate.

Level Income optionOnly members who contribute to Social Security are eligible to choose the Level Income option. This option increases your retirement by a percentage of the amount of Social Security benefit you are elegible to receive immediately. Your retirement benefit will later be reduced by the full amount of the Social Security benefit for which you are eligible to receive at the age you choose below. You must submit a Social Security estimate with your signature, dated within six (6) months of your retirement date, which will be used to calculate your Level Income amount.

A retiring member with a QILDRO on file with SERS may not choose Level Income without contacting the QILDRO Department at 217-524-6965. A retirement benefit including a QILDRO and Level Income will require additonal processing time.

I fully understand the Level Income option and agree my retirement benefit will be reduced at the age I elect.

Please check one:o I elect the Level Income option for age 62 years and 1 month.o I elect the Level Income option for the age at which I am eligible to receive my full Social Security benefit.o I do not elect the Level Income option, or it does not apply to me.

Special note for those electing the Level Income option: SERS benefits are paid for the current month (July’s payment is paid in July) and Social Security benefits are paid one month behind (July’s payment is paid in August); therefore, there will be one month you will receive a reduced benefit from SERS and you will not receive a Social Security benefit.

Reciprocal serviceDo you have service credit in any of the following systems? o Yes o NoIf yes, please check only the system(s) you wish to include when having your reciprocal benefit calculated. You must apply with all systems when you apply for a reciprocal retirement.

o Chicago Teachers’ Pension Fund o Laborers’ Annuity & Benefit Fund of Chicago

o County Employees’ Annuity & Benefit Fund of Cook County o Metropolitan Water Reclamation District Retirement Fund

o Forest Preserve District Employees’ Annuity & Benefit o Municipal Employees’ Annuity & Benefit Fund of Chicago

o General Assembly Retirement System o Park Employees’ Annuity & Benefit Fund of Chicago

o Judges’ Retirement System o Teachers’ Retirement System

o Illinois Municipal Retirement Fund o State Universities Retirement System

If I am currently receiving SERS disability benefits, I understand these benefits will be terminated and retirement benefits will begin.

By signing below I certify this information is correct and that I am aware that knowingly making a false statement of falsifying a record in an attempt to defraud SERS is a class 3 felony. I understand that if the SERS Board of Trustees has a reasonable suspicion that an attempt has been made to defraud SERS, it is required to report the matter to the appropriate State’s Attorney for investigation.

Member signature __________________________________________________________________ Date __________________________

84 srs.illinois.gov

Page 1 of 2

Member/payee informationName (Last, first, middle) SSN

Address (Street, City, State, Zip) Phone number(s)(H)

Email address (C)

SignatureI, the above designated payee, am receiving a monthly benefit from SERS. I hereby authorize SERS to forward such payments by electronic fund transfer to the financial institution indicated below, and the financial institution to credit the amounts thereof to the account listed below. This authority is to remain in full effect until my death, the end of my eligibility period, SERS has received notification from me of its termination (within a reasonable amount of time to act upon the termination request) or until SERS has sent me a 10-day advance written notice the agreement will be terminated.

I hereby acknowledge my monthly benefits terminate at the end of the month of my death or my eligibility period. I agree if any benefit payments to which I am not entitled have been received and collected by my financial institution, I, or we (if my account is a joint account), authorize and direct my financial institution to refund the same amount to SERS and charge such refund payments to the account listed below or any other account of mine. In the event the money has been withdrawn from the account listed below by any other of the undersigned, I authorize the financial institution to charge such refund payments to any other account we, individually or jointly, may have in said financial institution.

By signing below I certify this information is correct and that I am aware that knowingly making a false statement of falsifying a record in an attempt to defraud SERS is a class 3 felony. I understand that if the SERS Board of Trustees has a reasonable suspicion that an attempt has been made to defraud SERS, it is required to report the matter to the appropriate State’s Attorney for investigation.

Member signature ________________________________________________________________________ Date __________________________(Also includes Power of Attorney − must attach document, or legal guardian − must attach court order)

Joint account holder signature (if any) _______________________________________________________ Date ___________________________

Joint account holder signature (if any) _______________________________________________________ Date ___________________________

Financial institution information (to be completed by the financial institution)The undersigned, on behalf of the financial institution below, hereby accepts the depository agreement as set forth above and verifies the signatures of all persons having an interest in the account.

Name Account holders name(s)

Address (Street) Branch designation (if applicable)

(City, State, Zip) Phone number

o This account currently receives a direct deposit from the State of IL.

o Checking account o Savings account

ACH Routing number Account number Signature of authorized official Date





SERS


Direct Deposit Agreement for Benefit PaymentsPlease print or type.

217-785-7444Email: [email protected]

3967 (10/17)

srs.illinois.gov

srs.illinois.gov 85

Page 2 of 2

Direct Deposit InstructionsThe terms of this depository agreement may not amended by any party.SERS, through the Office of the Comptroller, has the ability to electronically deposit a payee’s monthly benefit to an authorized participating Automated Clearing House (ACH) Network financial institution. The financial institution may be any bank, savings bank, savings and loan association (or similar institution) or federal or state chartered credit union in which the payee has a checking or savings account participating in the ACH Network. In order for SERS to deposit the payee’s monthly benefit into a financial institution, the payee, any joint account holder and the financial institution must complete this form.

Member/payee informationThe payee’s name, social security number, address, home and/or cell phone number should be typed or printed in the appropriate boxes.

Signature (Account holder agreement)After reading the conditions of the depository agreement, the payee, Power of Attorney or legal guardian must sign and date the form. If a Power of Attorney signs the form on behalf of the payee, the Power of Attorney document must be attached to the form. If a legal guardian signs the form on behalf of the payee, letters of office or other similar court document(s) must be attached of the guardian is not the natural parent of the payee. If there are one or more joint account holders, all joint account holders must sign and date the form. If you’ve already submitted Power of Attorney and/or Guardian legal documents, you do not have to submit them again.

Financial institution agreementThe selected financial institution should complete all the information requested in this section. The monthly benefit may only be deposited in an account in which the payee has an interest. The routing number should reflect the number for electronic transfers which may be different from the routing number for the branch bank at which the account is held. By an authorized individual signing this form, the financial institution agrees to accept the electronic transfer from SERS on behalf of the payee and verifies all signatures of all persons having an interest in the payee’s account.

Upon completion of the form by account holders and financial institution, return to SERS by mail or fax for processing.

• Once your bank information is updated in the SERS system, you will receive notification your next check will be processed electronically.

• You can securely view your monthly earnings statement through the SRS Member Services website. To view your account information, you may register through our website at srs.illinois.gov and navigate to the link “vew PDF version on how to secure an ID.” You will find instructions for the one-time registration process that must be completed to access your account information online.

Termination of depository agreementThis depository agreement shall remain in effect until terminated by: • the death of the payee or the end of payee’s eligibility period; • cancellation by the payee, Power of Attorney or legal guardian by written notice to SERS (within a

reasonable amount of time to act upon the termination request); • a 10-day advance written notice from SERS to the payee indicating SERS’ termination of the agreement; or • the closing of the account by the payee or financial institution.

The amount of any payments received after termination should be returned to SERS by the financial institution or an account holder, along with a statement including the name of the payee, payee’s Social Security number and the date of the erroneous deposit.

86 srs.illinois.gov

Where to write for vital recordsAn official certificate of every birth, death, marriage and divorce are filed permanently either in a state, city, county, or local Vital Statistics Office. The Federal Government does not maintain files on these records.

To obtain a certified copy of an official certificate, write or visit the Vital Statistics Office in the state or area where the event occurred. Addresses for other Vital Statistics Offices located throughout the country, and the fees for each certificate are listed. The State Employees' Retirement System can also provide information on where to write for records on file in other states.

To ensure that you receive an accurate record, and that your request is filled quickly, follow the steps outlined below: •Writetotheappropriateofficewithyourrequest. •Forallcertifiedcopiesrequested,sendacheckor

money order payable for the number of copies you want. Cash is not recommended because the office cannot refund cash lost in transit.

•Typeorprintallnamesandaddressesintheletter.

List the following information when writing for birth and death records:1. Full name and sex of person whose record is being

requested.2. Parent's names, including maiden name.3. Month, day, and year of birth or death.4. Place of birth or death (city or town, county, state,

and name of hospital, if known).

5. Why the copy is needed.6. Relationship to person whose record is being

requested.

List the following information when writing for marriage records.1. Full names of bride and groom.2. Month, day and year of marriage.3. Place of marriage (city or town, county, and state).4. Why the copy is needed.5. Relationship to person whose record is being

requested.

List the following information when writing for divorce records.1. Full names of husband and wife.2. Date of divorce or annulment.3. Place of divorce or annulment.4. Type of final decree.5. Why the copy is needed.6. Relationship to person whose record is being

requested.

To obtain records for any of the events listed above that occurred in Illinois contact:

Division of Vital Records Illinois Department of Public Health 605 West Jefferson Street Springfield, IL 62702-5079 www.vitalrec.com

Miscellaneous forms

srs.illinois.gov 87

MEMBERSHIP RECORDThis Membership Record constitutes your permanent record with the State Employees' Retirement System of Illinois (System). All information furnished in this record is strictly confidential and is used only by the System in the establishment of your rights, privileges and benefits as a member of the System.

Tier:

Social Security Number: Employee ID Number:

Date of Birth: Sex:

You should notify the System promptly of any change in your beneficiary.

Name of Your Husband or Wife ______________________________________________ Date of Birth ____________ First Name Middle Name Last Name

Telephone: ( ) Email Address:

Name and Date of Birth of Unmarried Children Under Age 22:

Name Date of Birth Name Date of Birth

___________________________ _______________ ___________________________ _______________

___________________________ _______________ ___________________________ _______________

___________________________ _______________ ___________________________ _______________

___________________________ _______________ ___________________________ _______________

Name of Father, if living ___________________________________________________________________________ First Name Middle Name Last Name

Name of Mother, if living___________________________________________________________________________ First Name Middle Name Last Name

Do you have previous employment with the State of Illinois? Yes No

Check the Systems that you have credit in that may be considered under the Retirement Systems Reciprocal Act.

County Employees' Annuity & Benefit Fund of Cook County Municipal Employees' Annuity & Benefit Fund of Chicago Forest Preserve District Employees' Annuity & Benefit Fund of Cook County Park Employees' Annuity & Benefit Fund Illinois Municipal Retirement Fund Public School Teachers' Pension & Retirement Fund of Chicago Judges' Retirement System of Illinois State Employees' Retirement System Laborers' Annuity & Benefit Fund State Teachers' Retirement System Metropolitan Water Reclamation District Retirement Fund State Universities' Retirement System

Please complete the beneficiary information on the reverse side!100 (R-7-16) IL 589-0010




88 srs.illinois.gov

If the member dies before retirement the benefit will be paid as follows: 1. All the money will be paid to John A. Doe. 2. If John A. Doe is not living when the member dies, all the money will be paid to Jane B. Doe. 3. If John A. and Jane B. Doe are not living when the member dies, the money will be divided equally among David C., Nancy D. and Mary E. Doe. (If only two of these three persons are living when the member dies, each will receive one half of the money and if only one of these three persons is living when the member dies, he/she will receive all of the money.) 4. If John A., Jane B., David C., Nancy D. and Mary E. Doe are not living when the member dies, all the money will be paid to Frank F. Smith. 5. If none of the nominated beneficiaries are living when the member dies, all of the money will be paid to the member's estate.

NOMINATED BENEFICIARIES Order Number Name Address Relationship

THIS FORM MUST BE WITNESSED BY TWO PEOPLE WHO ARE NOT NAMED AS BENEFICIARIES.

Member's Signature_______________________________ Date__________________________________________

Member's Social Security Number ____________________________ Witness_______________________________________

Address_______________________________________

Witness_______________________________________ Address_______________________________________

MEMBER'S NOMINATION OF BENEFICIARY(IES) FOR DEATH BENEFITS This form is to be used to nominate the person or persons to receive any death benefit payable by the State Employees' Retirement System of Illinois. This is a legal document which, after preparation, may not be altered in any way by any person. A member desiring to change beneficiaries at a later date must complete a new Nomination of Beneficiary form. The form on file with the System that has the most recent date, with member's signature, will take precedence.

INSTRUCTIONS: Complete this form in ink. You may nominate one person, as many as you wish, or your estate. If additional space is required, write the names and their order number on a separate piece of paper and attach it to this form. If an additional piece of paper is required, make sure that it is signed, dated and witnessed. Benefits will be paid on a survivor basis in the numerical order you indicate. Two or more persons with the same order number will receive equal shares. NOTE! Persons nominated as beneficiaries without order numbers will be considered after those persons nominated with order numbers. Two or more persons nominated without order numbers will receive equal shares.

EXAMPLE

_____ _______________________ ______________________________________ ___________________

_____ _______________________ ______________________________________ ___________________

_____ _______________________ ______________________________________ ___________________

_____ _______________________ ______________________________________ ___________________

_____ _______________________ ______________________________________ ___________________

_____ _______________________ ______________________________________ ___________________

OrderNumber

Name Address Relationship

1 John A. Doe 123 West Main Chicago Il 60601 Father2 Jane B. Doe 123 West Main Chicago Il 60601 Mother3 Donald C. Doe 123 West Main Chicago Il 60601 Brother3 Nancy D. Doe 44 South Bud Springfield Il 62708 Sister3 Mary E. Doe 123 West Main Chicago Il 60601 Sister4 Frank F. Smith 9376 99th St. Pawnee Il 61605 Friend

srs.illinois.gov 89

CERTIFICATION OF RETIREE RETURN TO STATE EMPLOYMENT

IDENTIFICATION OF EMPLOYING AGENCY:

Department, Board, or Commission Payroll Code No.

Division or Institution Telephone No.

IDENTIFICATION AND CLASSIFICATION OF RETURNING EMPLOYEE:

Name Soc. Sec. # Address

Check one: *RETIREE: *ARCP: *CLSIP:

TO BE EMPLOYED AS FOLLOWS: YES NO ** Is retiree/employee to be employed on a NON-PERMANENT basis? (NOT more than 75 working days in any calendar year - any fraction of a day worked is to be considered a full working day). *** Is retiree/employee to be employed on a PERMANENT basis? (MORE than 75 working days in any calendar year - any fraction of a day worked is to be considered a full working day).

Current Year Date of Employment I hereby certify that the above information is correct to the best of my knowledge and belief.

SignatureofEmployee SignatureofAuthorizedOfficer Date

* Retiree: Currently retired or ERI Buy & Quit participant* ARCP: Alternative Retirement Cancellation Payment* CLSIP: Contingent Lump Sum Incentive Payment

** Employees being employed on a NON-PERMANENT basis do not contribute to the System during the period of NON-PERMANENT employment. Deductions should be made for FICA.

*** Employees returning to employment on a PERMANENT basis must contribute to both the System and FICA as of the date of employment.

3905 (R-6-06)

CERTIFICATION OF RETIREE RETURN TO STATE EMPLOYMENT

IDENTIFICATION OF EMPLOYING AGENCY:

Department, Board, or Commission Payroll Code No.

Division or Institution Telephone No.

IDENTIFICATION AND CLASSIFICATION OF RETURNING EMPLOYEE:

Name Soc. Sec. # Address

Check one: *RETIREE: *ARCP: *CLSIP:

TO BE EMPLOYED AS FOLLOWS: YES NO ** Is retiree/employee to be employed on a NON-PERMANENT basis? (NOT more than 75 working days in any calendar year - any fraction of a day worked is to be considered a full working day). *** Is retiree/employee to be employed on a PERMANENT basis? (MORE than 75 working days in any calendar year - any fraction of a day worked is to be considered a full working day).

Current Year Date of Employment I hereby certify that the above information is correct to the best of my knowledge and belief.

SignatureofEmployee SignatureofAuthorizedOfficer Date

* Retiree: Currently retired or ERI Buy & Quit participant* ARCP: Alternative Retirement Cancellation Payment* CLSIP: Contingent Lump Sum Incentive Payment

** Employees being employed on a NON-PERMANENT basis do not contribute to the System during the period of NON-PERMANENT employment. Deductions should be made for FICA.

*** Employees returning to employment on a PERMANENT basis must contribute to both the System and FICA as of the date of employment.

3905 (R-6-06)

(mm/dd/yyyy) (mm/dd/yyyy)







90 srs.illinois.gov

Form W-4PDepartment of the Treasury Internal Revenue Service

Withholding Certificate for Pension or Annuity Payments

OMB No. 1545-0074

2016Purpose. Form W-4P is for U.S. citizens, resident aliens, or their estates who are recipients of pensions, annuities (including commercial annuities), and certain other deferred compensation. Use Form W-4P to tell payers the correct amount of federal income tax to withhold from your payment(s). You also may use Form W-4P to choose (a) not to have any federal income tax withheld from the payment (except for eligible rollover distributions or payments to U.S. citizens delivered outside the United States or its possessions) or (b) to have an additional amount of tax withheld.

Your options depend on whether the payment is periodic, nonperiodic, or an eligible rollover distribution, as explained on pages 3 and 4. Your previously filed Form W-4P will remain in effect if you do not file a Form W-4P for 2016.

What do I need to do? Complete lines A through G of the Personal Allowances Worksheet. Use the additional worksheets on page 2 to further adjust your withholding allowances for itemized deductions, adjustments to income, any additional standard deduction, certain credits, or multiple pensions/more-than-one-income situations. If you do not want any federal income tax withheld (see Purpose, earlier), you can skip the worksheets and go directly to the Form W-4P below.Sign this form. Form W-4P is not valid unless you sign it.Future developments. The IRS has created a page on IRS.gov for information about Form W-4P and its instructions, at www.irs.gov/w4p. Information about any future developments affecting Form W-4P (such as legislation enacted after we release it) will be posted on that page.

Personal Allowances Worksheet (Keep for your records.)A Enter “1” for yourself if no one else can claim you as a dependent . . . . . . . . . . . . . . . . A

B Enter “1” if: {• You are single and have only one pension; or• You are married, have only one pension, and your spouse has no income subject to withholding; or . . . . . . . . . . . • 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.

} B

C Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a spouse who hasincome subject to withholding or 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 . . . . . DE Enter “1” if you will file as head of household on your tax return . . . . . . . . . . . . . . . . . EF Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.

• If your total income will be less than $70,000 ($100,000 if married), enter “2” for each eligible child; then less “1” ifyou have two to four eligible children or less “2” if you have five or more eligible children.• If your total income will be between $70,000 and $84,000 ($100,000 and $119,000 if married), enter “1” for eacheligible child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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

For accuracy, complete all worksheets that apply.

{ • If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions and Adjustments Worksheet on page 2. • If you are single and have more than one source of income subject to withholding or are

married and you and your spouse both have income subject to withholding and your combined income from all sources exceeds $50,000 ($20,000 if married), see the Multiple Pensions/More-Than-One-Income Worksheet on page 2 to avoid having too little tax withheld.

• If neither of the above situations applies, stop here and enter the number from line G on line 2 of Form W-4P below.

Separate here and give Form W-4P to the payer of your pension or annuity. Keep the top part for your records.

Form W-4PDepartment of the Treasury Internal Revenue Service

Withholding Certificate for Pension or Annuity Payments

▶ For Privacy Act and Paperwork Reduction Act Notice, see page 4.

OMB No. 1545-0074

2016Your first name and middle initial Last name Your social security number

Home address (number and street or rural route)

City or town, state, and ZIP code

Claim or identification number (if any) of your pension or annuity 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 line 2 or 3.) ▶

2 Total number of allowances and marital status you are claiming for withholding from each periodic pension or annuity payment. (You also may designate an additional dollar amount on line 3.) . . . . . . . . . . . ▶

(Enter number of allowances.)

Marital status: Single Married Married, but withhold at higher Single rate.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 ▶

Cat. No. 10225T Form W-4P (2016)

srs.illinois.gov 91

Form W-4P (2016) Page 2 Deductions and Adjustments Worksheet

Note: Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.

1 Enter an estimate of your 2016 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state and local taxes, medical expenses in excess of 10% (7.5% if either youor your spouse was born before January 2, 1952) of your income, and miscellaneous deductions. For 2016, you may have to reduce your itemized deductions if your income is over $311,300 and you are married filing jointly or are a qualifying widow(er); $285,350 if you are head of household; $259,400 ifyou are single and not head of household or a qualifying widow(er); or $155,650 if you are married filing separately. See Pub. 505 for details . . . . . . . . . . . . . . . . . . . . . . . 1 $

2 Enter: { $12,600 if married filing jointly or qualifying widow(er)$9,300 if head of household . . . . . . . . . . . .$6,300 if single or married filing separately

} 2 $

3 Subtract line 2 from line 1. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . . 3 $4 Enter an estimate of your 2016 adjustments to income and any additional standard deduction (see

Pub. 505) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 $5 Add lines 3 and 4 and enter the total. (Include any credit amounts from the Converting Credits to

Withholding Allowances for 2016 Form W-4 worksheet in Pub. 505.) . . . . . . . . . . . . 5 $6 Enter an estimate of your 2016 income not subject to withholding (such as dividends or interest) . . 6 $7 Subtract line 6 from line 5. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . . 7 $8 Divide the amount on line 7 by $4,050 and enter the result here. Drop any fraction . . . . . . . 89 Enter the number from the Personal Allowances Worksheet, line G, page 1 . . . . . . . . . 9

10 Add lines 8 and 9 and enter the total here. If you use the Multiple Pensions/More-Than-One-Income Worksheet, also enter this total on line 1 below. Otherwise, stop here and enter this total on FormW-4P, line 2, page 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Multiple Pensions/More-Than-One-Income WorksheetNote: Complete only if the instructions under line G, page 1, direct you here. This applies if you (and your spouse if married filing jointly) have more than one source of income subject to withholding (such as more than one pension, or a pension and a job, or you have a pension and your spouse works).

1 Enter the number from line G, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet) . . . . . . . . . . . . . . . . . . . . . . . . . . 1

2 Find the number in Table 1 below that applies to the LOWEST paying pension or job and enter it here. However, if you are married filing jointly and the amount from the highest paying pension or job is $65,000 or less, do not enter more than “3” . . . . . . . . . . . . . . . . . . . . 2

3 If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter “-0-”) and on Form W-4P, line 2, page 1. Do not use the rest of this worksheet . . . . . . . . 3

Note: If line 1 is less than line 2, enter “-0-” on Form W-4P, line 2, page 1. Complete lines 4 through 9 below to figure the additional withholding amount necessary to avoid a year-end tax bill.4 Enter the number from line 2 of this worksheet . . . . . . . . . . 45 Enter the number from line 1 of this worksheet . . . . . . . . . . 56 Subtract line 5 from line 4 . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Find the amount in Table 2 below that applies to the HIGHEST paying pension or job and enter it here 7 $8 Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . . 8 $9 Divide line 8 by the number of pay periods remaining in 2016. For example, divide by 12 if you are paid

every month and you complete this form in December 2015. Enter the result here and on Form W-4P, line 3, page 1. This is the additional amount to be withheld from each payment . . . . . . . . 9 $

Table 1Married Filing Jointly

If wages from LOWEST paying job or pension are—

Enter on line 2 above

$0 - $6,000 06,001 - 14,000 1

14,001 - 25,000 225,001 - 27,000 327,001 - 35,000 435,001 - 44,000 544,001 - 55,000 655,001 - 65,000 765,001 - 75,000 875,001 - 80,000 980,001 - 100,000 10

100,001 - 115,000 11115,001 - 130,000 12130,001 - 140,000 13140,001 - 150,000 14150,001 and over 15

All Others

If wages from LOWEST paying job or pension are—


$0 - $9,000 09,001 - 17,000 1

17,001 - 26,000 226,001 - 34,000 334,001 - 44,000 444,001 - 75,000 575,001 - 85,000 685,001 - 110,000 7

110,001 - 125,000 8125,001 - 140,000 9140,001 and over 10

Table 2Married Filing Jointly

If wages from HIGHEST paying job or pension are—


$0 - $75,000 $61075,001 - 135,000 1,010

135,001 - 205,000 1,130205,001 - 360,000 1,340360,001 - 405,000 1,420405,001 and over 1,600

All Others

If wages from HIGHEST paying job or pension are—


$0 - $38,000 $61038,001 - 85,000 1,01085,001 - 185,000 1,130

185,001 - 400,000 1,340400,001 and over 1,600

92 srs.illinois.gov

Form W-4P (2016) Page 3

Additional InstructionsSection references are to the Internal Revenue Code. When should I complete the form? Complete Form W-4P and give it to the payer as soon as possible. Get Pub. 505, Tax Withholding and Estimated Tax, to see how the dollar amount you are having withheld compares to your projected total federal income tax for 2016. You also may use the IRS Withholding Calculator at www.irs.gov/individuals for help in determining how many withholding allowances to claim on your Form W-4P.Multiple pensions/more-than-one-income. To figure the number of allowances that you may claim, combine allowances and income subject to withholding from all sources on one worksheet. You may file a Form W-4P with each pension payer, but do not claim the same allowances more than once. Your withholding usually will be most accurate when all allowances are claimed on the Form W-4P for the highest source of income subject to withholding and zero allowances are claimed on the others.Other income. If you have a large amount of income from other sources not subject to withholding (such as interest, dividends, or capital gains), consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Get Form 1040-ES and Pub. 505 at www.irs.gov/formspubs.

If you have income from wages, see Pub. 505 to find out if you should adjust your withholding on Form W-4 or Form W-4P.Note: Social security and railroad retirement payments may be includible in income. See Form W-4V, Voluntary Withholding Request, for information on voluntary withholding from these payments.

Withholding From Pensions and AnnuitiesGenerally, federal income tax withholding applies to the taxable part of payments made from pension, profit-sharing, stock bonus, annuity, and certain deferred compensation plans; from individual retirement arrangements (IRAs); and from commercial annuities. The method and rate of withholding depend on (a) the kind of payment you receive; (b) whether the payments are delivered outside the United States or its commonwealths and possessions; and (c) whether the recipient is a nonresident alien individual, a nonresident alien beneficiary, or a foreign estate. Qualified distributions from a Roth IRA are nontaxable and, therefore, not subject to withholding. See page 4 for special withholding rules that apply to payments outside the United States and payments to foreign persons.

Because your tax situation may change from year to year, you may want to refigure your withholding each year. You can change the amount to be withheld by using lines 2 and 3 of Form W-4P.Choosing not to have income tax withheld. You (or in the event of death, your beneficiary or estate) can choose not to have federal income tax withheld from your payments by using line 1 of Form W-4P. For an estate, the election to have no income tax withheld may be made by the executor or personal representative of the decedent. Enter the estate’s employer identification number (EIN) in the area reserved for “Your social security number” on Form W-4P.

You may not make this choice for eligible rollover distributions. See Eligible rollover distribution—20% withholding on page 4.

Caution: There are penalties for not paying enough federal income tax during the year, either through withholding or estimated tax payments. New retirees, especially, should see Pub. 505. It explains your estimated tax requirements and describes penalties in detail. You may be able to avoid quarterly estimated tax payments by having enough tax withheld from your pension or annuity using Form W-4P. Periodic payments. Withholding from periodic payments of a pension or annuity is figured in the same manner as withholding from wages. Periodic payments are made in installments at regular intervals over a period of more than 1 year. They may be paid annually, quarterly, monthly, etc.

If you want federal income tax to be withheld, you must designate the number of withholding allowances on line 2 of Form W-4P and indicate your marital status by checking the appropriate box. Under current law, you cannot designate a specific dollar amount to be withheld. However, you can designate an additional amount to be withheld on line 3.

If you do not want any federal income tax withheld from your periodic payments, check the box on line 1 of Form W-4P and submit the form to your payer. However, see Payments to Foreign Persons and Payments Outside the United States on page 4.Caution: If you do not submit Form W-4P to your payer, the payer must withhold on periodic payments as if you are married claiming three withholding allowances. Generally, this means that tax will be withheld if your pension or annuity is at least $1,720 a month.

If you submit a Form W-4P that does not contain your correct social security number (SSN), the payer must withhold as if you are single claiming zero withholding allowances even if you checked the box on line 1 to have no federal income tax withheld.

There are some kinds of periodic payments for which you cannot use Form W-4P because they are already defined as wages subject to federal income tax withholding. These payments include retirement pay for service in the U.S. Armed Forces and payments from certain nonqualified deferred compensation plans and deferred compensation plans described in section 457 of tax-exempt organizations. Your payer should be able to tell you whether Form W-4P applies.

For periodic payments, your Form W-4P stays in effect until you change or revoke it. Your payer must notify you each year of your right to choose not to have federal income tax withheld (if permitted) or to change your choice.Nonperiodic payments—10% withholding. Your payer must withhold at a flat 10% rate from nonperiodic payments (but see Eligible rollover distribution—20% withholding on page 4) unless you choose not to have federal income tax withheld. Distributions from an IRA that are payable on demand are treated as nonperiodic payments. You can choose not to have federal income tax withheld from a nonperiodic payment (if permitted) by submitting Form W-4P (containing your correct SSN) to your payer and checking the box on line 1. Generally, your choice not to have federal income tax withheld will apply to any later payment from the same plan. You cannot use line 2 for nonperiodic payments. But you may use line 3 to specify an additional amount that you want withheld.Caution: If you submit a Form W-4P that does not contain your correct SSN, the payer cannot honor your request not to have income tax withheld and must withhold 10% of the payment for federal income tax.

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Form W-4P (2016) Page 4

Eligible rollover distribution—20% withholding. Distributions you receive from qualified pension or annuity plans (for example, 401(k) pension plans and section 457(b) plans maintained by a governmental employer) or tax-sheltered annuities that are eligible to be rolled over tax free to an IRA or qualified plan are subject to a flat 20% federal withholding rate. The 20% withholding rate is required, and you cannot choose not to have income tax withheld from eligible rollover distributions. Do not give Form W-4P to your payer unless you want an additional amount withheld. Then, complete line 3 of Form W-4P and submit the form to your payer.Note: The payer will not withhold federal income tax if the entire distribution is transferred by the plan administrator in a direct rollover to a traditional IRA or another eligible retirement plan (if allowed by the plan), such as a qualified pension plan, governmental section 457(b) plan, section 403(b) contract, or tax-sheltered annuity.

Distributions that are (a) required by law, (b) one of a specified series of equal payments, or (c) qualifying “hardship” distributions are not “eligible rollover distributions” and are not subject to the mandatory 20% federal income tax withholding. See Pub. 505 for details. See also Nonperiodic payments—10% withholding on page 3.Tax relief for victims of terrorist attacks. For tax years ending after September 10, 2001, disability payments for injuries incurred as a direct result of a terrorist attack directed against the United States (or its allies), whether outside or within the United States, are not included in income. You may check the box on line 1 of Form W-4P and submit the form to your payer to have no federal income tax withheld from these disability payments. However, you must include in your income any amounts that you received or you would have received in retirement had you not become disabled as a result of a terrorist attack. See Pub. 3920, Tax Relief for Victims of Terrorist Attacks, for more details.

Changing Your “No Withholding” ChoicePeriodic payments. If you previously chose not to have federal income tax withheld and you now want withholding, complete another Form W-4P and submit it to your payer. If you want federal income tax withheld at the rate set by law (married with three allowances), write “Revoked” next to the checkbox on line 1 of the form. If you want tax withheld at any different rate, complete line 2 on the form.Nonperiodic payments. If you previously chose not to have federal income tax withheld and you now want withholding, write “Revoked” next to the checkbox on line 1 and submit Form W-4P to your payer.

Payments to Foreign Persons and Payments Outside the United StatesUnless you are a nonresident alien, withholding (in the manner described above) is required on any periodic or nonperiodic payments that are delivered to you outside the United States or its possessions. You cannot choose not to have federal income tax withheld on line 1 of Form W-4P. See Pub. 505 for details.

In the absence of a tax treaty exemption, nonresident aliens, nonresident alien beneficiaries, and foreign estates generally are subject to a 30% federal withholding tax under section 1441 on the taxable portion of a periodic or nonperiodic pension or annuity payment that is from U.S. sources. However, most tax treaties provide that private pensions and annuities are exempt from withholding and tax. Also, payments from certain pension plans are exempt from withholding even if no tax treaty applies. See Pub. 515, Withholding of Tax on Nonresident Aliens and Foreign Entities, and Pub. 519, U.S. Tax Guide for Aliens, for details. A foreign person should submit Form W-8BEN, Certificate of Foreign Status of Beneficial Owner for United States Tax Withholding, to the payer before receiving any payments. The Form W-8BEN must contain the foreign person’s taxpayer identification number (TIN).

Statement of Federal Income Tax Withheld From Your Pension or AnnuityBy January 31 of next year, your payer will furnish a statement to you on Form 1099-R, Distributions From Pensions, Annuities, Retirement or Profit-Sharing Plans, IRAs, Insurance Contracts, etc., showing the total amount of your pension or annuity payments and the total federal income tax withheld during the year. If you are a foreign person who has provided your payer with Form W-8BEN, your payer instead will furnish a statement to you on Form 1042-S, Foreign Person’s U.S. Source Income Subject to Withholding, by March 15 of next year.

Privacy Act and Paperwork Reduction Act NoticeWe ask for the information on this form to carry out the Internal Revenue laws of the United States. You are required to provide this information only if you want to (a) request federal income tax withholding from periodic pension or annuity payments based on your withholding allowances and marital status, (b) request additional federal income tax withholding from your pension or annuity, (c) choose not to have federal income tax withheld, when permitted, or (d) change or revoke a previous Form W-4P. To do any of the aforementioned, you are required by sections 3405(e) and 6109 and their regulations to provide the information requested on this form. Failure to provide this information may result in inaccurate withholding on your payment(s). Providing false or fraudulent information may subject you to penalties.

Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation, and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.

You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by section 6103.

The average time and expenses required to complete and file this form will vary depending on individual circumstances. For estimated averages, see the instructions for your income tax return.

If you have suggestions for making this form simpler, we would be happy to hear from you. See the instructions for your income tax return.

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