Cd-0773-0313 Spouse Rollover Election Form For Distribution From The Pension Fund
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1
2STATE OF NEW JERSEY • DEPARTMENT OF THE TREASURY
CD-0773-0313
DIVISION OF PENSIONS AND BENEFITS
PO BOX 295 • TRENTON, NJ 08625-0295
BENEFICIARY SERVICES
SPOUSE ROLLOVER ELECTION FORM
FOR DISTRIBUTION FROM THE PENSION FUND
(See the reverse side for instructions)
PART 1: Provide the following beneficiary information (please print).
1. Your
Name ___________________________________________
3. Soc. Sec. # ____________________________
Last
First
MI
2. Mailing
4. Daytime
Address __________________________________________
Phone # ______________________________
Street
Area Code
5. Deceased’s
________________________________________________
Membership # __________________________
City
State
Zi P
PART 2: This form must be completed and submitted to the Division of Pensions and Benefits before your payment can
be processed. Choose your preferred method of payment and check only one of the boxes below.
IMPORTANT: YOUR SELECTION IS IRREVOCABLE
For further information regarding your tax liability please see Fact Sheet #27, The Taxability and Mandatory
Withholding of Income Tax from your Pension Distribution. To obtain this publication visit our Web site:
or contact the Division’s Office of Client Services at (609) 292-7524.
Rollover is only available if the taxable portion of your payment is $200 or more.
1.
Payment to me and withhold 20% federal income tax on the taxable portion of my payment.
2.
Roll over the entire payment including any non-taxable portion to the following financial institution or
employer plan: _____________________________________________________________________________
This is an:
IRA
Inherited IRA
Eligible Employer Plan
Roth IRA
3.
A partial roll over of $ _______________ (dollar amount) of my payment to the following financial institution
or employer plan with the remaining amount paid to me (after withholding 20% federal income tax on the taxable
portion): __________________________________________________________________________________
This is an:
IRA
Inherited IRA
Eligible Employer Plan
Roth IRA
Please note that the rollover payment will include an allocable portion of any after-tax contributions.
By signing this Spouse Rollover Election Form I certify that I have read Fact Sheet #27, The Taxability and Mandatory
Withholding of Income Tax from your Pension Distribution, and fully understand the tax options available to me including
the option to rollover my benefit to an IRA or Eligible Employer Plan. I further certify that, if I have elected a rollover under
option 2 or 3 above, the receiving IRA or eligible employer plan is eligible to receive my rollover from this qualified plan (as
described in Fact Sheet #27) and will accept any after-tax contributions included in my rollover.
__________________________________________________________ ________________________________________________
Signature
Date
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