Fillable Printable Form 5079
Fillable Printable Form 5079
Form 5079
Page 1 of 2 SOI-F35
POST RETIREMENT DISTRIBUTI ON OF
ANNUITY SAVINGS ACCOUNT APPLICATION
State Form 50798 (R7 / 2-15)
Approved by State Board of Accounts, 2015
INDIANA PUBLIC RETIREMENT SYSTEM
1 North Capitol Avenue, Suite 001
Indianapolis, IN 46204-2014
Telephone: (888) 286-3544 (Toll-free)
Fax: (866) 591-9441 (Toll-free)
E-mail: [email protected]
Web site: www.inprs.in.gov
Your Social Security number is being requested by this agency pursuant to the requirements of Internal Revenue Code 3405. This
disclosure is mandator y and this form cannot be processed without this informatio n
INSTRUCTIONS
1. Remove the instruction pages inclu ded with this form prior to returning the completed form to INPRS at the address shown on
the form.
2. Type or print using black ink, compl ete all i nformation, and place the Member’s name and Social Security number at the top of
each page as requested.
3. This completed form may be mailed or faxed to the address indicated above.
4. If you have any changes to the information on this form such as name or address, contact Custom er Service at (888) 286-3544,
Monday – Friday, 8 a.m. – 8 p.m. EST.
Select the appropriate fund:
Public Employees’ Retirement Fund (PERF) Teachers’ Retirement Fund (T RF)
MEMBER INFORMATION
Member’s name
Social Security number (last 4 digits)
Pension ID (PID) number
Address (number and street)
Telephone number with area code
City
State
ZIP Code
Date of retirement
(mm/dd/yyyy)
ELECTION FOR ANNUITY SAVINGS ACCOUNT (ASA) PAYMENT
Select one of the following six options. This selection cannot be changed by Indiana Publi c Retirement System (INPRS) once this
form has been received.
AS A 1: I elect to receive the total amount of my ASA paid as a monthly benefit. I understand that I will not receive any
distribution from my ASA other than this monthly benefit. Note: By choosing this option, you are increasing your monthly
benefit; therefore, you may want to change your monthly tax withholdings. To do this, submit the Annuitant’s Request for
State and County Income Tax Withholding (State Form 37365) Form WH-4P and the Withholding Certificate for Pension or
Annuity Payments (Form W-4P) available on the INPRS Web site.
AS A 2: I elect to have the total amount of my ASA, less the mandatory withholding for federal income tax and any optio nal
State of Indiana tax withholding, paid directly to me. If you want Indiana State income tax withheld, submit the Annuitant’s
Request for State and County Income Tax Withholding (State Form 3736 5) Form WH-4P available on the INPRS Web site.
AS A 3: I elect to have all of the taxable portion of my ASA paid in the form of a direct rollover to an Individual Retirement
Account (IRA) or a Qualified Retirement Plan that has provisions allowing it to accept the rollover on my behalf. The non-
taxable portion will be paid directly to me. Complete the ROLLOVER INFORMATION section of this form.
AS A 4: I elect to have a part of the taxable portion of my ASA paid in the form of a direct rollover to an Individual Retir ement
Account (IRA) or a Qualified Retirement Plan that has provisions allowing it to accept the rollover on my behalf. The non-
taxable portion will be paid directly to me. Also, the part of the taxable portion of the distribution that is not directly rolled over
(less the mandatory withholding for federal income tax and any optiona l State of Indiana tax withho lding) will be paid directly
to me. If you want Indiana State income tax withh eld, submit the Annuitant’s Request for State and County Income Tax
Withholding (State Form 37365) (Form WH-4P) available on the INPRS Web site. Complete the ROLLOVER INFORMATION
section of this form.
Partial Rollover Percentage
%
AS A 6: I elect to receive a distribution of an amount equal to my tax basis (after-tax contribution) in my ASA balance as it
existed on December 31, 1986, and defer distribution of the remainder of my ASA until a later date. My account will continue to
be invested with INPRS under the same guidelines applicable to an ASA.
AS A 7: I elect to receive a distribution of an amount equal to my tax basis (after-tax contribution) in my ASA balance as it
existed on December 31, 1986, and to receiv e the balance of the account as a monthly benefit. Note: By choosing this option,
you are increasing your monthly benefit; therefore, you may want to change your monthl y tax withholdings. To do this, submit
the Annuitant’s Request for State and County Income Tax Withholding (State Form 37365) F orm W H-4P and the Withholding
Certificate for Pension or Annuity Payments (Form W-4P) avail able on the INPRS Web site or from the State forms Web site
located at http://forms.in.gov
.
Reset Form
Page 2 of 2 SOI-F35
Member’s name
Social Security number (last 4 digits)
Pension ID (PID) number
ROLLOVER INFORMATION
Rollovers may be split between two entities. You must provide the name of the entity/entities and the percentage of distribution to be
made to each. You may also want to seek professional tax advice prior to making distribu tion decisions. If you choose to take a
rollover distribution and do not complete the rollover by the 60th day following the day on which you receive the distribution, your
distribution may be subject to taxes and/or penalties unless you qualify for a waiver. Consult your tax adv isor for waiver
qualifications.
I represent that the designated plan is an IRA or Qualified Retirement Pla n that has provisions allowing it to accept direct rollovers on
my behalf. The Indiana Public Retirement System should make the direct rollover check for the Partial R ollover Amount payable to:
Rollover Institution No. 1
Name of eligible retirement plan or eligible IRA (complete only if you select a rollover).
(This must be the complete name of the eligible plan or eligible IRA as reported by the trustee to the Internal Revenue Service.)
Percent of partial distribution to be made to this institution %
Rollover Institution No. 2
Name of eligible retirement plan or eligible IRA (complete only if you select a rollover).
(This must be the complete name of the eligible plan or eligible IRA as reported by the trustee to the Internal Revenue Service.)
Percent of partial distribution to be made to this institution %
MEMBER AUTHORIZATION
I hereby affirm that I am the above named applicant and that I have personally prepared the aforegoing application. I further affirm
that I have read and understand the different alternatives listed. I understand that my account is subject to market changes until the
date of processing, which may take up to 30 days. I further understand that I can make daily c hanges to my investment elections
until processing takes place. I hereby direct the Indiana Public Retirement System to process my Annuity Savings Account in the
aforegoing selected manner.
Member’s signature
Date (mm/dd/yyyy)
NOTE: If this form is being signed by an Attorney-in-Fact or Legal Guardian, copies of the corresponding Power of Attorney or
Guardianship of the person must accompany this application.
Changes to your ASA and/or RSA allocations may be done by accessing your account online at www.inprs.in.gov, or by contacting a
Customer Service Representative, Toll-free at (888) 286-3544.
Changes to beneficiary desi gnations may be done by submitting a Change of Beneficiary (State Form 52332) to INPRS, by
accessing your account online, or by contacting a Customer Service Representative. T his form is available from the INPRS Web site
at www.inprs.in.gov
.
IC 5-10.2, IC 5-10.4, and IC 5-10.5 et seq.
SPECIAL TAX NOTICE REGARDING PLAN PAYMENTS
Your Rollover Options for Payments
Provided with the Post Retirement Distribution of Annuity Savings Account Application
State Form 50798
Page 1 of 4 SOI-F35
You are receiving this notice b ecause all or a portion of a payment you are receiving from the Plan is eligible to be rolled over to an IRA
or an eligible emplo yer plan. This notice is intended to help you decide whether to do such a rollover.
Rules that apply to most payments from a plan are described in the “General Information About Rollovers” section. Special rules that
only apply in certain circumstances are described in the “Special Rules and Options” section.
GENERAL INFORMATION ABOUT ROLLOVERS
How can a rollover affect my taxes?
You will be taxed on a payment from the Plan if you do not roll it over. If you are under age 59½ and do not do a rollover, you will al so
have to pay a 10% additional income tax on early distributions (unless an exception ap plies). However, if you do a rollover of your plan
distribution to other than a Roth IRA, you will not have to p ay tax until you receive payments later and the 10% additi onal income tax
will not apply if those payments are made after you are age 59½ (or if an e xception applies).
Where may I roll over the payment?
You may roll over the payment to either an IRA (an individual retirement account or individual retirement annuity) or an eligible
employer plan (a tax- qualified plan, section 403(b) plan, or governmental section 457(b) plan) that will accept the rollover. The rules of
the IRA or employer plan that holds the rollover will determine your investment options, fees, and rights to payment from the IRA or
employer plan (for example, no spousal consent rules apply to IRAs and IRAs may not provide loans). Further, the amount rolled over
will become subject to the tax rules that apply to the IRA or employer plan.
How do I do a rollover?
There are two ways to do a rollover. Yo u can do either a direct rollover or a 60-day rollover.
If you do a direct rollover
, the Plan will make the payme nt di rectly to your IRA or an employer plan. You should contact the IRA sponsor
or the administrator of the employer plan for information on how to do a direct rollover.
If you do not do a direct rollover
, you may still roll over all or a part of that payment by making a deposit into an IRA or an eligible
employer plan that will accept it. You will have 60 days after you receive the payment to make the deposit. If you do not do a direct
rollover, the Plan is required to withhold 20% of the taxable portion of the payment for federal income ta xes (up to the amount of cash
received). This means that, in order to roll over the entire payment in a 60-day rollover, you must use other funds to make up for the
20% withheld. If you do not roll over the entir e taxable portion of the payment, the portion not rolled over will be taxed and will be
subject to the 10% additional income tax on early distributions if you are under age 59½ (unl ess an exception applies).
How much may I roll over?
If you wish to do a rollover, you may roll over all or part of the amount eli gib le for rollover. Any payment from the Plan is eligible for
rollover, except:
Certain payments spread ove r a period of at least 10 years or over your life or life expectancy (or the liv es or joint life expectancy of
you and your beneficiary)
Required minimum distributions after age 70½ (or after dea th)
Hardship distributions
Corrective distributions of cont ributions that exceed tax law limitations
Loans treated as deemed distributions (for example, loans in default due to missed paym ents before your employment ends)
Cost of life insurance paid by the Plan
The Plan administrator or the pa yor can tell you what portion of a payment is eligible for rollover.
If I don’t do a rollover, will I have to pay the 10% additional income tax on early distributions?
If you are under age 59½, you will have to pay the 10% additional income tax on ear ly distributions for any taxa ble portion of the
payment from the Plan (including amounts withheld for income tax) that you do not roll over, unless one of the exceptions listed below
applies. This tax is in addition to the regular income tax on the pa yment not rolled over.
The 10% additiona l income tax does not apply to the following pa yments from the Plan:
Payments made after you separate from service if you will be at least age 55 in the year of the separation
Payments that start after you separate from service if paid at least annually in equal or close to equal amounts over your life or life
expectancy (or the lives or joint life e xpect ancy of you and your benefici ary)
Payments from a governmental defined benefit pension plan made after you separate from service if you are a public safety
employee and you are at least age 50 in the year of the separation
Payments made due to disability
Payments after your death
Corrective distributions of cont ributions that exceed tax law limitations
Cost of life insurance paid by the Plan
Payments made directly to the government to satisfy a federal tax levy
SPECIAL TAX NOTICE REGARDING PLAN PAYMENTS
Your Rollover Options for Payments
Provided with the Post Retirement Distribution of Annuity Savings Account Application
State Form 50798
Page 2 of 4 SOI-F35
Payments made under a qualified domestic relations order (QDRO)
Payments up to the amount of your deductible medical expenses
Certain payments made while you are on active duty if you were a member of a reserve component called to duty after September
11, 2001, for more than 179 days
If I do a rollover to an IRA, will the 10% addition al income tax apply to early distributions from the IRA?
If you receive a payment from an IRA when you are under age 59½, you will have to pay the 10% additional income tax on early
distributions from the IRA, unless an exception appli es. In general, the exceptions to the 10% additional income tax for early
distributions from an IRA are the same as the exceptions listed above for early distributions from a plan. However, there are a few
differences for payments from an IRA, including:
There is no exception for payments made after separation from service in a year in which you are at least age 55.
The exception for qualified domestic relations orders (QDROs) does not apply (although a special rule applies under which, as part
of a divorce or separation agreement, a tax-free transfer may be made directl y to an IRA of a spouse or former spouse).
The exception for pa yments made at least annually in equal or close-to-equa l amounts over a specified period applies without
regard to whether you h ave h ad a separation from service.
There are additional exceptions for (1) payments for qualified higher educati on expenses, (2) payments up to $10,000 us ed in a
qualified first-time home purchase, and (3) payments for health insurance premiums after you have received unempl oyment
compensation for 12 consecutive weeks (or would have been eligib le to receive unemployment compensation b ut for self-
employed status).
Will I owe State income taxes?
This notice does not describe any State or local income tax rules (includin g withholding rules).
SPECIAL RULES AND OPTIONS
If your payment includes after-ta x contributions
After-tax contributions included in a payment are not taxed. If a payment is only part of your benefit, an allocable portion of your after-
tax contributions is included in the payment, so you cannot take a payment of only after-tax contributions. However, if you have pre-
1987 after-tax contributions maintained in a s eparate account, a special rule may apply to determine whether the after-tax contributions
are included in a payment. In addition, sp ecial rules apply when you do a rollover, as described belo w.
You may roll over to an IRA a payment that includes after-tax contributio ns through either a direct rollover or a 60-day rollover. You
must keep track of the aggregate amount of the after-tax contributions in all of your IRAs (in order to determine your taxable income for
later payments from the IRAs).
If you do a direct rollover of only a portion of the amount paid from the Plan and at the same time the rest is paid to you, the portion
directly rolled over consists first of the amount that would be taxable if not rolled over. For exampl e, assume you are receiving a
distribution of $12,000, of which $2,000 is after-tax contrib utions. In this case, if you directly roll over $10,000 to an IRA that is not a
Roth IRA, no amount is taxable because the $2,000 amount not directly rolled over is treated as after-tax contributions. If you do a
direct rollover of the entire amount paid fro m the Plan to two or more destinations at the same time, you can choose which destination
receives the after-tax contributions.
If you do a 60-day rollover to an IRA of only a portion of a payment made to you, the after-tax contributions are treated as rolled over
last. For example, assume you are receiving a distribution of $12,000, of which $2,000 is after-tax contributions, and no part of the
distribution is directly rolled over. In this case, if you roll over $10,000 to an IRA that is not a Roth IRA in a 60-day rollover, no amount is
taxable because the $2,000 amount not rolled over is treated as being after-tax contributions.
You may roll over to an employer pl an all of a payment that includes after-tax contributions, but only through a direct rollover (and only if
the receiving plan separate ly accounts for after-tax contributions and is not a governmental section 457(b) pla n). You can do a 60-d a y
rollover to an employer plan of part of a payment that includes after-tax contributions, but only up to the amount of the payment that
would be taxable if not rolled over.
If you miss the 60-day rollover deadline
Generally, the 60-day rollover deadline cannot be extended. However, the IRS has the limited auth ority to waive the deadline u nder
certain extraordinary circumstances, such as when external events prevented you from completing the rollover by the 60-day rollover
deadline. To apply for a waiver, you must file a private letter ruling request with the IRS. Private letter ruling requests require the
payment of a nonrefundable us er fee. F or more information , see IRS Publication 590-A, Contributions to Individual Retirement
Arrangements (IRAs).
SPECIAL TAX NOTICE REGARDING PLAN PAYMENTS
Your Rollover Options for Payments
Provided with the Post Retirement Distribution of Annuity Savings Account Application
State Form 50798
Page 3 of 4 SOI-F35
If you have an outstanding loan that is being offset
If you have an outstanding loan from the Plan, your Plan benefit may be offset by the amount of the loan, typically when your
employment ends. The loan offset amount is treated as a distribution to you at the time of the offset and will be taxed (including the
10% additional income tax on early distributions, unless an exception applies) unless you do a 60-day rollover in the amount of the loan
offset to an IRA or employer plan.
If you were born on or before January 1, 1936
If you were born on or before Janu ary 1, 1936, and receive a lump-sum dist ribution that you do not roll over, special rules for calculating
the amount of the tax on the payment might appl y to you. F or more information, see IRS Publication 575, Pension and Annuity Income.
If you are an eligible retired public safety officer and your pension payment is used to pay for health coverage or qualified
long-term care insurance
If the Plan is a governmental plan, you retired as a pu blic safety officer, and your retirement was by reason of disability or was after
normal retirement age, you can exclude from your taxable income plan payments paid directly as premiums to an accident or health
plan (or a qualified long-term care insurance contract) that your employer maintains for you, your spouse, or your dependents, up to a
maximum of $3,000 annually. For this purpose, a public safety officer is a law enforcement officer, firefighter, chaplain, or member of a
rescue squad or ambulance crew.
If you roll over your payment to a Roth IRA
If you roll over the payment to a Roth IRA, a special rule applies under which the amount of the payment rolled over (reduced by any
after-tax amounts) will be taxed. However, the 10% ad ditional income tax on early distributions will not apply (unless you take the
amount rolled over out of the Roth IRA within 5 years, counting from January 1 of the year of the rollover).
If you roll over the payment to a Roth IRA, later payments from the Roth IRA that are qualified distributions will not be taxed (including
earnings after the rollover). A qualifie d distribution from a Roth IRA is a payment made after you are age 59½ (or after your death or
disability, or as a qualified first-time home bu yer distribution of up to $10,000) and after you have had a R oth IRA for at least 5 years. In
applying this 5-year rul e, you count from January 1 of the year for which your first contribution was made to a Roth IRA. Payments from
the Roth IRA that are not qualified distributions will be taxe d to the extent of earnings after the rollover, including the 10% additional
income tax on early distributions (unless an exception applies). You do not have to take re quired minimum distributions from a Roth IRA
during your lifetime. For more information, see IRS Publication 590-A, Contributions to Indi vidual Retirement Arrangements (IRAs), and
IRS Publication 590-B, Distributions from Individual Retirement Arrangements (IRAs).
You cannot roll over a distribution to a designated Roth account in an other employer’s plan.
If you are not a plan participant
Payments after death of the participant — If you receive a distribution after a participant’s death that you do not roll over, the
distribution will generally be taxed in the same manner descr ibed elsewhere in this notice. However, the 10% additional income tax on
early distributions will not apply. In addition, the special rules for public safet y officers do not apply. The speci al rul e described under the
section “If you were born on or before January 1, 1936” applies only if the participant was born on or befor e January 1, 1936.
If you are a surviving spouse — If you receive a payment from the Plan as the surviving spouse of a de ceased participant, you
have the same rollover options that the participant would have had, as described elsewhere in this notice. In addition, if you choose
to do a roll
over to an IRA, you may treat the IRA as your own or as an inherited IRA.
An IRA you treat as your own is treated like any other IRA of yours, so that payments made to you before you are age 59½ will be
subject to the 10% additional income tax on early distributions (unless an exception ap plies) and required minimum distributions from
your IRA do not have to start until after you are age 70½.
If you treat the IRA as an inherited IRA, payments from the IRA will not be subject to the 10% additi onal income tax on early
distributions. However, if the participant had started taking re quired minimum distributions, you will have to receive requ ired minimum
distributions from the inherited IRA. If the participant had not started taking required minimum distributions from the Plan , you will not
have to start receiving required minimum dist ributions from the inherited IRA until the year the participant would have been age 70½.
If you are a surviving beneficiary other than a spouse — If you receive a payment from the Plan because of a participant’s death
and you are a designated beneficiary other than a surviving spouse, the only rollover option you have is to do a direct rollover to an
inherited IRA. Payments from the inherited IRA will not be subject to the 10% additional income tax on early distributions. You will
have to receive required mini mum distributions from the inherited IRA.
Payments under a qualified domestic relations order — If you are the spouse or former spouse of a p articip ant and you receive a
payment from the Plan under a qualified domestic relations order (QDRO), you generally have the same options the participant would
have (for example, you may roll over the payment to your own IRA or an eligi bl e emplo yer plan that will accept it). Payments under the
QDRO will not be subject to the 10% additional income tax on early distributions.
SPECIAL TAX NOTICE REGARDING PLAN PAYMENTS
Your Rollover Options for Payments
Provided with the Post Retirement Distribution of Annuity Savings Account Application
State Form 50798
Page 4 of 4 SOI-F35
If you are a nonresident alien
If you are a nonresident alien and you do not do a direct rollover to a U.S. IRA or U.S. employer pla n, instead of withholding 20%, the
Plan is generally required to withhold 3 0% of the pa yment for federal income taxes. If the amount withheld exceeds the amount of tax
you owe (as may happen if you do a 60-da y r ollover), you may request an income tax refund by filing Form 1040 NR and attaching your
Form 1042-S. See Form W-8BEN for claiming that you are entitled to a reduced rate of withholding under an income tax treaty. For
more information, see also IRS Publication 519, U.S. Tax Guide for Aliens, and IRS Publi c ation 515, Withholding of T ax on Nonresident
Aliens and Foreign Entities.
Other special rules
If a payment is one in a series of payments for less than 10 years, your choi ce whether to make a direct rollover will apply to all later
payments in the series (unless you make a different choice for later payments).
If your payments for the year are less than $200, the Plan is not required to allow you to do a direct rollover and is not required to
withhold for federal income taxes. However, you may do a 60-day rollover.
You may have special rollover rights if you recently served in the U.S. Armed Forces. For more information, see IRS Pu blication 3,
Armed Forces’ Tax Guide.
FOR MORE INFORMATION
You may wish to consult with the Plan adminis trator or payor, or a professional tax advisor, before taking a payment from the Plan.
Also, you can find more detailed information on the federal tax treatment of payments from emplo yer plans in: IRS Publication 575,
Pension and Annuity Income; IRS Publication 590-A, Contributions to Individual Retirement Arrangements (IRAs); IRS Publication 590-
B, Distributions from Individual Retirement Arrangements (IRAs); and IRS Publication 571, Tax-Sheltered Annuit y Plans (403(b) Plans).
These publications are available from a local IRS office, on the web at www.irs.gov
, or by calling 800-TAX-FORM.
