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Page 1: Form 5: Application for Withdrawal of Accumulated ... · PDF filemaryland state retirement agency 120 east baltimore street baltimore, maryland 21202-6700 application for withdrawal

MARYLAND STATE RETIREMENT AGENCY120 EAST BALTIMORE STREET

BALTIMORE, MARYLAND 21202-6700

APPLICATION FOR WITHDRAWAL

OF ACCUMULATED CONTRIBUTIONS RETIREMENT USE ONLY Form 5 (REV. 7/16)

Purpose of this form: This form is used by an individual to request a withdrawal of his or her balance of

accumulated contributions from the Maryland State Retirement and Pension System (System). An individual

is eligible to request a withdrawal only if he or she has resigned or has been terminated from the position

which made the person eligible to participate in the System. If you have not resigned your position or you

have not been terminated from your position you are not eligible to withdraw your balance of accumulated

contributions from the System.

INSTRUCTIONS

For assistance in completing this form, please view the training video on the Maryland State Retirement

Agency’s website at sra.maryland.gov. This video provides important information and step-by-step instructions

for properly completing this form.

Please print in ink, using one space per letter or•

number and skip a space between words.

Keep a copy of the completed form for your•

records.

The original, completed form must be returned to•

the Maryland State Retirement Agency, 120 E.

Baltimore Street, Baltimore, Maryland 21202-

6700.

The top portion of this form (Section I) is to be•

completed by the person who is applying to with-

draw his or her balance of accumulated contribu-

tions from the System.

Your signature on this form must be notarized.•

Do not sign on the Member’s Signature line until•

you are in the presence of a Notary Public who

can notarize your signature.

If your resignation/termination date is less than•

six months from the date that you are completing

and submitting this form, a representative from

your former employer’s human resources depart-

ment must complete the bottom portion of the

form (Section II), titled “To be completed by the

Retirement Coordinator,” before you submit the

completed form to the Retirement Agency.

A signed copy of Form 746 Acknowledgement of•

Receipt Special Tax Notice Regarding YourRollover Options must be submitted with this

form.

If you choose Refund Choice No. 1 you do not•

need to complete the Form 193 Trustee-to-Trustee Distribution Form for Rollovers.

If you choose Refund Choice No. 2 or Refund•

Choice No. 3 a completed copy of the Form 193

Trustee-to-Trustee Distribution Form forRollovers must be submitted with this form.

Please allow up to 90 days from the latter of the•

Retirement Agency’s receipt of your payroll con-

tribution (the last pay period from your resigna-

tion/termination) or the receipt of your properly

completed forms for the Retirement Agency to

process your request. Refund checks are print-

ed and mailed on the last day of each month.

Refunds are paid by paper checks which are•

mailed to the address that you provide on this

form. Note: Even if you requested to roll over all

or a portion of your refund, all checks are mailed

to you at the address provided on this form.

The Retirement Agency will withhold federal•

taxes equal to 20% and Maryland state taxes

(only if you are a Maryland resident) equal to

7.75% of the refund amount not rolled over to

another qualified retirement plan.

If, after reviewing the training video, you need•

additional assistance to complete this form, you

may call 410-625-5555 or toll-free 1-800-492-

5909.

FORM 5 (7/16) Page 1 of 2

Page 2: Form 5: Application for Withdrawal of Accumulated ... · PDF filemaryland state retirement agency 120 east baltimore street baltimore, maryland 21202-6700 application for withdrawal

NAME

First Initial Last

Number and Street

Retirement Coordinator Signature Date Telephone Number

Name of the Employing Agency at Resignation/Termination Email Address

Daytime Telephone Number

A rollover of after-tax amounts is only permitted to an IRA or as a direct rollover to a 401(a) plan or 403(b) annuity that agrees to separately account for the after-tax amounts. Any employer pick-up contributions transferred under payment choices 2 or 3 lose their post tax status for Maryland income tax purposes. Mandatoryfederal income tax withholding is at the rate of 20% on the taxable amount paid to you.

PLEASE READ THE FREQUENTLY ASKED QUESTIONS AND SPECIAL TAX NOTICE BEFORE SELECTING YOUR CHOICE. CHECK ONE:

RETIREMENT COORDINATOR COMPLETES THIS SECTION EMPLOYING AGENCY NAME: ______________________________________

This member’s resignation/termination date is: ______________ This member’s pay period ending date is: ______________Section 828 of the Pension Protection Act of 2006 provides for a waiver of the ten percent (10%) early withdrawal penalty tax on certain distributions

by pension plans to qualified public safety employees. Qualified public safety employees are defined by the Act as any employee of a State or political

subdivision of a State who provides police protection, fire-fighting services or emergency medical services. Does this member or former member meet

the definition of a qualified public safety employee with respect to his/her employment with you? _____ Yes _____ NoI certify that the above information regarding resignation/termination date and eligibility under section 828 of the Pension Protection Act is true andaccurate to the best of my knowledge and that I am authorized to certify this information by my employer.

____________________________________________ _________________ _(______)____________________________

TO THE BOARD OF TRUSTEES: I apply for the withdrawal of my accumulated contributions with interest earned and thereby terminate my membership in the MarylandState Retirement and Pension System and forfeit any further right to receive a future benefit, including disability retirement benefits. I have read and under-stand the Summary of Major Retirement Benefits. I have read and signed the enclosed Special Tax Notice Regarding Plan Payments (IRS Safe Harbor Explanation).

SOCIAL SECURITY NUMBER

HOME ADDRESS

City State ZIP Code-

- -

- -

Refund $__________________ to me. Balance trans-ferred to an “eligible retirement plan” (Traditional IRA,401(a) plan, 403(a) or (b) annuity, 408A Roth IRA or457(b) governmental plan.) (If transferring to a 457(b)governmental plan or 403(a) annuity plan, the mini-mum payable to me is the non-taxable amount, if any.)

REFUND CHOICE NO. 2(Complete Form 193)

Entire amount transferred to an “eligible retirementplan” (Traditional IRA, 401(a) plan, 403(a) or (b)annuity, 408A Roth IRA or 457(b) governmentalplan.) Both 457(b) governmental plans and 403(a)annuity plans prohibit a rollover of non-taxablefunds from this plan.)

Entire amount refundedto me.

REFUND CHOICE NO. 1REFUND CHOICE NO. 3

(Complete Form 193)

Member’s Signature (Must sign in presence of notary)______________________________________________ Date _________________

Month Day Year

DATE OF BIRTH

- -

Are you a resident of Maryland? No ___ Yes ___ (For Maryland residents, State income tax withholding of 7.75% will be withheld from the taxable amount paid to you.)

Resignation/Termination Date:

Have you submitted a claim for disability? No ___ Yes ___ If Yes, know that by completing and submitting this form, you are forfeiting all rights to a future benefit,including disability, and your disability claim will be terminated.Are you terminating from an approved leave of absence and from employment? No ___ Yes ___ If Yes, give date terminated: Are you transferring to a State Agency, County Board of Education, or Participating Governmental Unit? No ___ Yes ___If yes, give name of new employing agency ________________________________________________________________

Mo. Day Yr.

- -

Mo. Day Yr.

- -

If date entered is less than six months from date this form is signed, return completedform to your former employer’s retirement coordinator to complete bottom section.

FORM 5 (7/16) Page 2 of 2

SECTION I — To be completed by the Withdrawal Applicant

SECTION II — To be completed by the Retirement Coordinator

Page 3: Form 5: Application for Withdrawal of Accumulated ... · PDF filemaryland state retirement agency 120 east baltimore street baltimore, maryland 21202-6700 application for withdrawal

IMPO

RTA

NT:

PLE

ASE

REA

D “

SUM

MA

RY

OF

MA

JOR

RET

IREM

ENT

BEN

EFIT

S”

BEN

EFIT

S

S

YST

EMS

N

on-C

ontri

buto

ry /C

ontri

buto

ry

Pens

ion

Syst

em

Alte

rnat

e C

ontri

buto

ry

Pens

ion

Sele

ctio

n Pl

an –

enr

olle

d be

fore

7/1

/201

1

Ref

orm

ed C

ontri

buto

ry P

ensi

on

Ben

efit

– En

rolle

d on

or a

fter J

uly

1, 2

011

Ret

irem

ent S

yste

m –

Not

e:

Bifu

rcat

ed m

embe

rs a

re in

the

Retir

emen

t Sys

tem

but

rece

ive

a co

mbi

natio

n be

nefit

from

bot

h th

e Re

tirem

ent &

app

licab

le P

ensi

on S

yste

m

Serv

ice

Ret

irem

ent

El

igib

ility

For

mul

a

Mem

bers

enr

olle

d pr

ior t

o 7/

1/20

11:

Age

62

with

at l

east

5 y

ears

of e

ligib

ility

se

rvic

e, O

R

Age

63

with

at l

east

4 y

ears

of e

ligib

ility

se

rvic

e, O

R

Age

64

with

at l

east

3 y

ears

of e

ligib

ility

se

rvic

e, O

R

Age

65

or o

lder

with

at l

east

2 y

ears

of

elig

ibili

ty se

rvic

e, O

R

At l

east

30

year

s of e

ligib

ility

serv

ice

rega

rdle

ss o

f age

. M

embe

rs e

nrol

led

7/1/

2011

or l

ater

: Se

e R

efor

med

Con

tribu

tory

Pen

sion

se

ctio

n N

on-C

ontri

buto

ry P

ensi

on:

.8%

of

aver

age

final

com

pens

atio

n up

to S

ocia

l Se

curit

y in

tegr

atio

n le

vel,

plus

1.5

% o

f av

erag

e fin

al c

ompe

nsat

ion

in e

xces

s of

the

Soci

al S

ecur

ity In

tegr

atio

n Le

vel,

times

cre

dita

ble

serv

ice.

C

ontri

buto

ry P

ensi

on: 1

.2%

of a

vera

ge

final

com

pens

atio

n tim

es se

rvic

e cr

edit

as

of Ju

ne 3

0, 1

998,

plu

s 1.4

% o

f ave

rage

fin

al c

ompe

nsat

ion

times

cre

dita

ble

serv

ice

earn

ed a

fter J

une

30, 1

998.

Age

62

with

at l

east

5 y

ears

of e

ligib

ility

se

rvic

e, O

R

Age

63

with

at l

east

4 y

ears

of e

ligib

ility

se

rvic

e, O

R

Age

64

with

at l

east

3 y

ears

of e

ligib

ility

se

rvic

e, O

R

Age

65

or o

lder

with

at l

east

2 y

ears

of

elig

ibili

ty se

rvic

e, O

R

At l

east

30

year

s of e

ligib

ility

serv

ice

rega

rdle

ss o

f age

. 1.

2% o

f ave

rage

fina

l com

pens

atio

n tim

es c

redi

tabl

e se

rvic

e as

of J

une

30,

1998

, plu

s 1.8

% o

f ave

rage

fina

l co

mpe

nsat

ion

afte

r Jun

e 30

, 199

8.

Age

65

with

at l

east

10

year

s of

el

igib

ility

serv

ice,

OR

R

ule

of 9

0 (s

um o

f age

and

elig

ibili

ty

serv

ice

equa

l 90)

. 1.

5% o

f ave

rage

fina

l com

pens

atio

n tim

es c

redi

tabl

e se

rvic

e.

At l

east

age

60,

rega

rdle

ss o

f cre

dita

ble

serv

ice,

OR

A

t lea

st 3

0 ye

ars o

f cre

dita

ble

serv

ice,

re

gard

less

of a

ge.

1.8%

of a

vera

ge fi

nal c

ompe

nsat

ion

times

cre

dita

ble

serv

ice.

Page 4: Form 5: Application for Withdrawal of Accumulated ... · PDF filemaryland state retirement agency 120 east baltimore street baltimore, maryland 21202-6700 application for withdrawal

BEN

EFIT

S

S

YST

EMS

N

on-C

ontri

buto

ry /C

ontri

buto

ry

Pens

ion

Syst

em

Alte

rnat

e C

ontri

buto

ry

Pens

ion

Sele

ctio

n Pl

an –

enr

olle

d be

fore

7/1

/201

1

Ref

orm

ed C

ontri

buto

ry P

ensi

on

Ben

efit

– En

rolle

d on

or a

fter J

uly

1, 2

011

Ret

irem

ent S

yste

m –

Not

e:

Bifu

rcat

ed m

embe

rs a

re in

the

Retir

emen

t Sys

tem

but

rece

ive

a co

mbi

natio

n be

nefit

from

bot

h th

e Re

tirem

ent &

app

licab

le P

ensi

on S

yste

m

Ear

ly

Ret

irem

ent

El

igib

ility

E

arly

R

etir

emen

t

Form

ula

Mem

ber e

nrol

led

prio

r to

7/1/

2011

: A

t lea

st a

ge 5

5 w

ith a

t lea

st 1

5 ye

ars o

f el

igib

ility

serv

ice.

M

embe

r enr

olle

d 7/

1/20

11 o

r lat

er:

At l

east

age

60

with

at l

east

15

year

s of

elig

ibili

ty se

rvic

e M

embe

r enr

olle

d pr

ior t

o 7/

1/20

11:

Sam

e as

serv

ice

retir

emen

t for

mul

a, b

ut

redu

ced

.005

tim

es th

e nu

mbe

r of m

onth

s to

age

62.

Max

imum

redu

ctio

n of

42%

. M

embe

r enr

olle

d 7/

1/20

11 a

nd la

ter:

Sam

e as

serv

ice

retir

emen

t for

mul

a, b

ut

redu

ced

.005

tim

es th

e nu

mbe

r of m

onth

s to

age

65.

Max

imum

redu

ctio

n of

30%

.

At l

east

age

55

with

at l

east

15

year

s of

elig

ibili

ty se

rvic

e.

Sam

e as

serv

ice

retir

emen

t for

mul

a, b

ut

redu

ced

.005

tim

es th

e nu

mbe

r of m

onth

s to

age

62.

Max

imum

redu

ctio

n of

42%

. Fo

r mem

bers

who

ear

n se

rvic

e cr

edit

on a

te

n m

onth

bas

is, t

he re

duct

ion

is .0

06 fo

r ea

ch m

onth

prio

r to

age

62.

At l

east

age

60

with

at l

east

15

year

s of

elig

ibili

ty se

rvic

e.

Sam

e as

serv

ice

retir

emen

t for

mul

a, b

ut

redu

ced

.005

tim

es th

e nu

mbe

r of m

onth

s to

age

65.

Max

imum

redu

ctio

n of

30%

. Fo

r mem

bers

who

ear

n se

rvic

e cr

edit

on a

te

n m

onth

bas

is, t

he re

duct

ion

is .0

06 fo

r ea

ch m

onth

prio

r to

age

65.

At l

east

25

year

s of c

redi

tabl

e se

rvic

e.

Sam

e as

serv

ice

retir

emen

t for

mul

a, b

ut

redu

ced

.005

tim

es th

e le

sser

of t

he

num

ber o

f mon

ths t

o ag

e 60

or 3

0 ye

ars

of se

rvic

e. F

or m

embe

rs w

ho e

arn

serv

ice

cred

it on

a te

n m

onth

bas

is, t

he re

duct

ion

is .0

06 fo

r eac

h m

onth

prio

r to

30 y

ears

.

Ves

ted

Serv

ice

Ret

irem

ent

Elig

ibili

ty

For

mul

a

Mem

ber e

nrol

led

prio

r to

7/1/

2011

: A

t lea

st 5

yea

rs o

f elig

ibili

ty se

rvic

e.

Mem

ber e

nrol

led

7/1/

2011

or l

ater

: A

t lea

st 1

0 ye

ars o

f elig

ibili

ty se

rvic

e.

Mem

ber e

nrol

led

prio

r to

7/1/

2011

: Sa

me

as se

rvic

e fo

rmul

a w

ith b

enef

its

begi

nnin

g at

age

62,

OR

an

early

serv

ice

retir

emen

t if e

ligib

le.

Mem

ber e

nrol

led

7/1/

2011

or l

ater

: Sa

me

as se

rvic

e fo

rmul

a w

ith b

enef

its

begi

nnin

g at

age

65,

OR

an

early

serv

ice

retir

emen

t if e

ligib

le.

At l

east

5 y

ears

of e

ligib

ility

serv

ice.

Sa

me

as se

rvic

e fo

rmul

a w

ith b

enef

its

begi

nnin

g at

age

62,

OR

an

early

serv

ice

retir

emen

t if e

ligib

le.

At l

east

10

year

s of e

ligib

ility

serv

ice.

Sa

me

as se

rvic

e fo

rmul

a w

ith b

enef

its

begi

nnin

g at

age

65,

OR

an

early

serv

ice

retir

emen

t if e

ligib

le.

At l

east

5 y

ears

of e

ligib

ility

serv

ice.

Sa

me

as se

rvic

e fo

rmul

a w

ith b

enef

its

begi

nnin

g at

age

60.

Page 5: Form 5: Application for Withdrawal of Accumulated ... · PDF filemaryland state retirement agency 120 east baltimore street baltimore, maryland 21202-6700 application for withdrawal

BEN

EFIT

S

S

YST

EMS

N

on-C

ontri

buto

ry /C

ontri

buto

ry

Pens

ion

Syst

em

Alte

rnat

e C

ontri

buto

ry

Pens

ion

Sele

ctio

n Pl

an –

enr

olle

d be

fore

7/1

/201

1

Ref

orm

ed C

ontri

buto

ry P

ensi

on

Ben

efit

– En

rolle

d on

or a

fter J

uly

1, 2

011

Ret

irem

ent S

yste

m –

Not

e:

Bifu

rcat

ed m

embe

rs a

re in

the

Retir

emen

t Sys

tem

but

rece

ive

a co

mbi

natio

n be

nefit

from

bot

h th

e Re

tirem

ent &

app

licab

le P

ensi

on S

yste

m

Ord

inar

y D

isab

ility

R

etir

emen

t E

ligib

ility

F

orm

ula

Perm

anen

tly d

isab

led

afte

r 5 y

ears

of

elig

ibili

ty se

rvic

e.

Mem

ber e

nrol

led

prio

r to

7/1/

2011

: Sa

me

as se

rvic

e re

tirem

ent f

orm

ula

usin

g cr

edita

ble

serv

ice

proj

ecte

d to

age

62.

M

embe

r enr

olle

d pr

ior t

o 7/

1/20

11:

Sam

e as

serv

ice

retir

emen

t for

mul

a us

ing

cred

itabl

e se

rvic

e pr

ojec

ted

to a

ge 6

5.

Perm

anen

tly d

isab

led

afte

r 5 y

ears

of

elig

ibili

ty se

rvic

e.

Sam

e as

serv

ice

retir

emen

t for

mul

a us

ing

cred

itabl

e se

rvic

e pr

ojec

ted

to a

ge 6

2.

Perm

anen

tly d

isab

led

afte

r 5 y

ears

of

elig

ibili

ty se

rvic

e.

Sam

e as

serv

ice

retir

emen

t for

mul

a us

ing

cred

itabl

e se

rvic

e pr

ojec

ted

to a

ge 6

5.

Perm

anen

tly d

isab

led

afte

r 5 y

ears

of

elig

ibili

ty se

rvic

e.

Sam

e as

serv

ice

retir

emen

t for

mul

a w

ith

a m

inim

um o

f 25%

of a

vera

ge fi

nal

com

pens

atio

n or

a fo

rmul

a us

ing

cred

itabl

e se

rvic

e pr

ojec

ted

to a

ge 6

0.

Acc

iden

tal

Dis

abili

ty

Ret

irem

ent

Elig

ibili

ty

Acc

iden

tal

Dis

abili

ty

Ret

irem

ent

Fo

rmul

a

Perm

anen

tly a

nd to

tally

dis

able

d by

an

acci

dent

in th

e pe

rfor

man

ce o

f dut

y.

2/3

of a

vera

ge fi

nal c

ompe

nsat

ion

plus

ac

cum

ulat

ed c

ontri

butio

ns p

aid

as a

n an

nuity

.

Perm

anen

tly a

nd to

tally

dis

able

d by

an

acci

dent

in th

e pe

rfor

man

ce o

f dut

y.

2/3

of a

vera

ge fi

nal c

ompe

nsat

ion

plus

ac

cum

ulat

ed c

ontri

butio

ns p

aid

as a

n an

nuity

.

Perm

anen

tly a

nd to

tally

dis

able

d by

an

acci

dent

in th

e pe

rfor

man

ce o

f dut

y.

2/3

of a

vera

ge fi

nal c

ompe

nsat

ion

plus

ac

cum

ulat

ed c

ontri

butio

ns p

aid

as a

n an

nuity

.

Perm

anen

tly a

nd to

tally

dis

able

d by

an

acci

dent

in th

e pe

rfor

man

ce o

f dut

y.

2/3

of a

vera

ge fi

nal c

ompe

nsat

ion

plus

ac

cum

ulat

ed c

ontri

butio

ns p

aid

as a

n an

nuity

.

Page 6: Form 5: Application for Withdrawal of Accumulated ... · PDF filemaryland state retirement agency 120 east baltimore street baltimore, maryland 21202-6700 application for withdrawal

BEN

EFIT

S

S

YST

EMS

N

on-C

ontri

buto

ry /C

ontri

buto

ry

Pens

ion

Syst

em

Alte

rnat

e C

ontri

buto

ry

Pens

ion

Sele

ctio

n Pl

an –

enr

olle

d be

fore

7/1

/201

1

Ref

orm

ed C

ontri

buto

ry P

ensi

on

Ben

efit

– En

rolle

d on

or a

fter J

uly

1, 2

011

Ret

irem

ent S

yste

m –

Not

e:

Bifu

rcat

ed m

embe

rs a

re in

the

Retir

emen

t Sys

tem

but

rece

ive

a co

mbi

natio

n be

nefit

from

bot

h th

e Re

tirem

ent &

app

licab

le P

ensi

on S

yste

m

Cos

t-of

-Liv

ing

Adj

ustm

ent t

o R

etir

emen

t B

enef

it E

ligib

ility

Form

ula

Ret

ired

at le

ast 1

yea

r as o

f Jul

y 1st

. M

embe

r enr

olle

d pr

ior t

o 7/

1/20

11:

Any

ann

ual a

djus

tmen

t bas

ed o

n ch

ange

s in

the

Con

sum

er P

rice

Inde

x. A

ny a

nnua

l ad

just

men

t lim

ited

to a

max

imum

of 3

%

of th

e in

itial

/cur

rent

(for

non

-C

ontri

buto

ry/C

ontri

buto

ry p

lan)

re

tirem

ent b

enef

it fo

r ser

vice

cre

dit

earn

ed b

y 7/

1/20

11. S

ervi

ce a

fter

7/1/

2011

ear

ns a

djus

tmen

t cap

ped

at

2.5%

if a

ssum

ed ra

te o

f ret

urn

for

inve

stm

ents

in p

rior c

alen

dar y

ear i

s met

ot

herw

ise

1% if

inve

stm

ent t

arge

t not

m

et.

Mem

ber e

nrol

led

7/1/

2011

or l

ater

: A

ny a

nnua

l adj

ustm

ent b

ased

on

Con

sum

er P

rice

Inde

x. L

imite

d to

2.5

%

if as

sum

ed ra

te o

f ret

urn

for i

nves

tmen

ts

is p

rior c

alen

dar y

ear m

et o

ther

wis

e 1%

if

inve

stm

ent t

arge

t not

met

.

Ret

ired

at le

ast 1

yea

r as o

f Jul

y 1st

. A

ny a

nnua

l adj

ustm

ent b

ased

on

chan

ges

in th

e C

onsu

mer

Pric

e In

dex.

Any

ann

ual

adju

stm

ent l

imite

d to

a m

axim

um o

f 3%

of

the

curr

ent r

etire

men

t ben

efit

for

serv

ice

cred

it ea

rned

by

7/1/

2011

. Se

rvic

e af

ter 7

/1/2

011

earn

s adj

ustm

ent

capp

ed a

t 2.5

% if

ass

umed

rate

of r

etur

n fo

r inv

estm

ents

in p

rior c

alen

dar y

ear i

s m

et o

ther

wis

e 1%

if in

vest

men

t tar

get n

ot

met

.

Ret

ired

at le

ast 1

yea

r as o

f Jul

y 1st

. A

ny a

nnua

l adj

ustm

ent b

ased

on

Con

sum

er P

rice

Inde

x. C

appe

d at

2.5

% if

as

sum

ed ra

te o

f ret

urn

for i

nves

tmen

ts is

pr

ior c

alen

dar y

ear m

et o

ther

wis

e 1%

if

inve

stm

ent t

arge

t not

met

.

Ret

ired

at le

ast 1

yea

r as o

f Jul

y 1st

. A

ny a

nnua

l adj

ustm

ent b

ased

on

Con

sum

er P

rice

Inde

x. U

nlim

ited

annu

al

adju

stm

ent f

or P

lan

A; m

axim

um o

f 5%

fo

r Pla

n B

; and

a c

ombi

natio

n fo

r Pla

n C

ba

sed

upon

pre

viou

s and

cur

rent

pla

ns o

f pa

rtici

patio

n.

Dea

th B

enef

its –

If

you

die

bef

ore

retir

emen

t whi

le

activ

ely

empl

oyed

or

whi

le o

n an

ap

prov

ed le

ave

of

abse

nce

and

you

have

at l

east

one

ye

ar o

f elig

ibili

ty.

Ben

efic

iary

may

re

ceiv

e:

(1) a

sing

le p

aym

ent o

f you

r acc

umul

ated

co

ntrib

utio

ns p

lus y

our a

nnua

l sal

ary.

If

you

r sol

e pr

imar

y be

nefic

iary

is y

our

spou

se, t

he sp

ouse

may

cho

ose

a m

onth

ly

allo

wan

ce in

stea

d of

the

abov

e be

nefit

, if

you:

(1) w

ere

elig

ible

to re

tire;

or (

2) h

ad

25 y

ears

of e

ligib

ility

serv

ice,

or (

3) w

ere

age

55 o

r old

er a

nd h

ad a

t lea

st 1

5 ye

ars

of e

ligib

ility

serv

ice.

If

you

are

kill

ed in

the

line

of d

uty,

di

ffer

ent b

enef

its a

re p

aid

to y

our e

ligib

le

spou

se, m

inor

chi

ldre

n, o

r dep

ende

nt

pare

nt.

(1) a

sing

le p

aym

ent o

f you

r acc

umul

ated

co

ntrib

utio

ns p

lus y

our a

nnua

l sal

ary.

If

you

r sol

e pr

imar

y be

nefic

iary

is y

our

spou

se, t

he sp

ouse

may

cho

ose

a m

onth

ly

allo

wan

ce in

stea

d of

the

abov

e be

nefit

, if

you:

(1) w

ere

elig

ible

to re

tire;

or (

2) h

ad

25 y

ears

of e

ligib

ility

serv

ice,

or (

3) w

ere

age

55 o

r old

er a

nd h

ad a

t lea

st 1

5 ye

ars

of e

ligib

ility

serv

ice.

If

you

are

kill

ed in

the

line

of d

uty,

di

ffer

ent b

enef

its a

re p

aid

to y

our e

ligib

le

spou

se, m

inor

chi

ldre

n, o

r dep

ende

nt

pare

nt.

(1) a

sing

le p

aym

ent o

f you

r ac

cum

ulat

ed c

ontri

butio

ns p

lus y

our

annu

al sa

lary

. If

you

r sol

e pr

imar

y be

nefic

iary

is y

our

spou

se, t

he sp

ouse

may

cho

ose

a m

onth

ly

allo

wan

ce in

stea

d of

the

abov

e be

nefit

, if

you:

(1) w

ere

elig

ible

to re

tire;

or (

2) h

ad

25 y

ears

of e

ligib

ility

serv

ice,

or (

3) w

ere

age

55 o

r old

er a

nd h

ad a

t lea

st 1

5 ye

ars

of e

ligib

ility

serv

ice.

If

you

are

kill

ed in

the

line

of d

uty,

di

ffer

ent b

enef

its a

re p

aid

to y

our e

ligib

le

spou

se, m

inor

chi

ldre

n, o

r dep

ende

nt

pare

nt.

(1) a

sing

le p

aym

ent o

f you

r acc

umul

ated

co

ntrib

utio

ns p

lus y

our a

nnua

l sal

ary.

If

you

r sol

e pr

imar

y be

nefic

iary

is y

our

spou

se, t

he sp

ouse

may

cho

ose

a m

onth

ly

allo

wan

ce in

stea

d of

the

abov

e be

nefit

, if

you:

(1) w

ere

elig

ible

to re

tire;

or (

2) h

ad

25 y

ears

of c

redi

tabl

e se

rvic

e, o

r (3)

wer

e ag

e 55

or o

lder

and

had

at l

east

15

year

s of

cre

dita

ble

serv

ice.

If

you

are

kill

ed in

the

line

of d

uty,

di

ffer

ent b

enef

its a

re p

aid

to y

our e

ligib

le

spou

se, m

inor

chi

ldre

n, o

r dep

ende

nt

pare

nt.

Page 7: Form 5: Application for Withdrawal of Accumulated ... · PDF filemaryland state retirement agency 120 east baltimore street baltimore, maryland 21202-6700 application for withdrawal

POL

ICE

PL

AN

S ST

ATE

PO

LIC

E R

ETIR

EMEN

T SY

STEM

1.

S

ervi

ce R

etir

emen

t: a

t age

50,

or w

ith 2

2 ye

ars (

25 y

ears

for m

embe

rs e

nrol

led

7/1/

2011

or l

ater

) of e

ligib

ility

serv

ice.

2.

V

este

d R

etir

emen

t: a

t age

50

if yo

u ha

ve a

t lea

st 5

yea

rs (1

0 ye

ars f

or m

embe

rs e

nrol

led

7/1/

2011

or l

ater

) of e

ligib

ility

serv

ice.

3.

O

rdin

ary

Dis

abili

ty R

etir

emen

t: If

you

are

per

man

ently

inca

paci

tate

d w

ith a

t lea

st 5

yea

rs o

f elig

ibili

ty se

rvic

e, re

gard

less

of a

ge.

4.

Spe

cial

Dis

abili

ty R

etir

emen

t: If

you

are

per

man

ently

inca

paci

tate

d in

the

perf

orm

ance

of d

uty,

rega

rdle

ss o

f age

or c

redi

tabl

e se

rvic

e.

5.

Cos

t-of

-Liv

ing

Adj

ustm

ent t

o R

etir

emen

t Ben

efit:

Mus

t be

retir

ed a

t lea

st o

ne y

ear a

s of J

uly

1. A

ny a

nnua

l adj

ustm

ent b

ased

on

chan

ges i

n th

e C

onsu

mer

Pric

e In

dex.

Any

ann

ual

adju

stm

ent u

nlim

ited

for s

ervi

ce c

redi

t ear

ned

by 7

/1/2

011.

Ser

vice

afte

r 7/1

/201

1 ea

rns a

djus

tmen

t cap

ped

at 2

.5%

if a

ssum

ed ra

te o

f ret

urn

for i

nves

tmen

ts in

prio

r cal

enda

r yea

r is m

et

othe

rwis

e 1%

if in

vest

men

t tar

get n

ot m

et.

CO

RR

ECTI

ON

AL

OFF

ICER

S’ R

ETIR

EMEN

T SY

STEM

1.

Se

rvic

e R

etir

emen

t: a

t age

55

for a

cor

rect

iona

l off

icer

in th

e fir

st si

x jo

b cl

assi

ficat

ions

; a d

eten

tion

cent

er o

ffic

er e

mpl

oyed

by

a pa

rtici

patin

g go

vern

men

tal u

nit;

a m

embe

r ser

ving

as

a co

rrec

tiona

l die

tary

, mai

nten

ance

, lau

ndry

, or s

uppl

y of

ficer

; a m

embe

r ser

ving

as a

Mar

ylan

d C

orre

ctio

nal E

nter

pris

es o

ffic

er, o

ffic

er tr

aine

e, p

lant

supe

rvis

or, p

lant

man

ager

, or

regi

onal

man

ager

, OR

at a

ge 6

0 fo

r a se

curit

y at

tend

ant a

t the

Clif

ton

T. P

erki

ns H

ospi

tal C

ente

r. O

R, h

ave

20 y

ears

of e

ligib

ility

serv

ice,

the

last

five

yea

rs o

f whi

ch m

ust b

e as

a

mem

ber i

n on

e of

the

clas

sific

atio

ns li

sted

abo

ve.

2.

Ves

ted

Ret

irem

ent:

Req

uire

s at l

east

5 y

ears

(10

year

s for

mem

bers

enr

olle

d 7/

1/20

11 o

r lat

er) o

f elig

ibili

ty se

rvic

e.

3.

Ord

inar

y D

isab

ility

Ret

irem

ent:

If y

ou a

re p

erm

anen

tly in

capa

cita

ted

with

at l

east

5 y

ears

of e

ligib

ility

serv

ice,

rega

rdle

ss o

f age

. 4.

A

ccid

enta

l Dis

abili

ty R

etir

emen

t: If

you

are

per

man

ently

inca

paci

tate

d in

the

perf

orm

ance

of d

uty,

rega

rdle

ss o

f age

or c

redi

tabl

e se

rvic

e.

5.

Cos

t-of

-Liv

ing

Adj

ustm

ent t

o R

etir

emen

t Ben

efit:

Mus

t be

retir

ed a

t lea

st o

ne y

ear a

s of J

uly

1. A

ny a

nnua

l adj

ustm

ent b

ased

on

chan

ges i

n th

e C

onsu

mer

Pric

e In

dex.

Any

ann

ual

adju

stm

ent u

nlim

ited

for s

ervi

ce c

redi

t ear

ned

by 7

/1/2

011.

Ser

vice

afte

r 7/1

/201

1 ea

rns a

djus

tmen

t cap

ped

at 2

.5%

if a

ssum

ed ra

te o

f ret

urn

for i

nves

tmen

ts in

prio

r cal

enda

r yea

r is m

et

othe

rwis

e 1%

if in

vest

men

t tar

get n

ot m

et.

LAW

EN

FOR

CEM

ENT

OFF

ICER

S’ P

ENSI

ON

PLA

N

1.

Serv

ice

Ret

irem

ent:

at a

ge 5

0 or

with

25

year

s of e

ligib

ility

serv

ice.

2.

V

este

d R

etir

emen

t: a

t age

50

with

at l

east

5 y

ears

(10

year

s for

mem

bers

enr

olle

d 7/

1/20

11 o

r lat

er) o

f elig

ibili

ty se

rvic

e.

3.

Ord

inar

y D

isab

ility

Ret

irem

ent:

If y

ou a

re p

erm

anen

tly in

capa

cita

ted

with

at l

east

5 y

ears

of e

ligib

ility

serv

ice,

rega

rdle

ss o

f age

. 4.

A

ccid

enta

l Dis

abili

ty R

etir

emen

t: If

you

are

per

man

ently

inca

paci

tate

d in

the

perf

orm

ance

of d

uty,

rega

rdle

ss o

f age

or c

redi

tabl

e se

rvic

e.

5.

Cos

t-of

-Liv

ing

Adj

ustm

ent t

o R

etir

emen

t Ben

efit:

Mus

t be

retir

ed a

t lea

st o

ne y

ear a

s of J

uly

1. A

ny a

nnua

l adj

ustm

ent b

ased

on

chan

ges i

n th

e C

onsu

mer

Pric

e In

dex.

Any

ann

ual

adju

stm

ent l

imite

d to

a m

axim

um o

f 3%

of t

he c

urre

nt re

tirem

ent b

enef

it fo

r ser

vice

cre

dit e

arne

d by

7/1

/201

1. S

ervi

ce a

fter 7

/1/2

011

earn

s adj

ustm

ent c

appe

d at

2.5

% if

ass

umed

rate

of

retu

rn fo

r inv

estm

ents

in p

rior c

alen

dar y

ear i

s met

oth

erw

ise

1% if

inve

stm

ent t

arge

t not

met

.

O

TH

ER

RE

TIR

EM

EN

T S

YST

EM

S JU

DG

ES’ R

ETIR

EMEN

T SY

STEM

1.

Fo

r an

indi

vidu

al w

ho w

as a

mem

ber o

f the

Judg

es’ R

etire

men

t Sys

tem

on

or b

efor

e Ju

ne 3

0, 2

012:

a.

A

Ret

irem

ent A

llow

ance

if: (

1) Y

ou a

re a

t lea

st a

ge 6

0 re

gard

less

of t

he y

ears

of c

redi

tabl

e se

rvic

e as

a ju

dge

or (2

) You

resi

gn b

ecau

se o

f an

inca

paci

tatin

g ill

ness

rega

rdle

ss o

f age

or

yea

rs o

f cre

dita

ble

serv

ice

as a

judg

e.

b.

A V

este

d R

etir

emen

t Allo

wan

ce: A

t age

60

if yo

u le

ave

your

acc

umul

ated

con

tribu

tions

on

depo

sit w

ith th

e M

aryl

and

Stat

e R

etire

men

t Age

ncy.

2.

Fo

r an

indi

vidu

al w

ho w

as a

mem

ber o

f the

Judg

es’ R

etire

men

t Sys

tem

on

or a

fter J

uly

1, 2

012:

a.

A

Ret

irem

ent A

llow

ance

if: (

1) Y

ou a

re a

t lea

st a

ge 6

0 an

d ha

ve a

t lea

st fi

ve y

ears

of e

ligib

ility

serv

ice

or (2

) You

resi

gn b

ecau

se o

f an

inca

paci

tatin

g ill

ness

rega

rdle

ss o

f age

or

year

s of c

redi

tabl

e se

rvic

e as

a ju

dge.

b.

A

Ves

ted

Ret

irem

ent A

llow

ance

: At a

ge 6

0 if

you

have

at l

east

five

yea

rs o

f elig

ibili

ty se

rvic

e an

d if

you

leav

e yo

ur a

ccum

ulat

ed c

ontri

butio

ns o

n de

posi

t with

the

Mar

ylan

d St

ate

Ret

irem

ent A

genc

y.

LEG

ISLA

TIV

E PE

NSI

ON

SY

STEM

- Fo

r mem

bers

of t

he L

egis

lativ

e Pe

nsio

n Sy

stem

, ple

ase

call

the

Mar

ylan

d St

ate

Ret

irem

ent A

genc

y fo

r inf

orm

atio

n.

If y

ou w

ish

to a

pply

for

one

of th

e be

nefit

s, co

ntac

t you

r em

ploy

er’s

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irem

ent c

oord

inat

or o

r a

retir

emen

t ben

efits

spec

ialis

t at 4

10-6

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555

or to

ll-fr

ee a

t 1-8

00-

492-

5909

for

the

appr

opri

ate

form

or

for

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tiona

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eep

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rmat

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for

your

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