Calstrs Refund Application Form – Fill Out and Use This PDF

GENERAL INFORMATION

Before refunding, read the applicable section of the Member Handbook to make sure you fully understand the consequences.

You may choose to refund your contributions and interest if you terminate CalSTRS-covered employment. If you worked in a CalSTRS-covered position after January 1, 2001, you have two accounts: a Defined Benefit account and a Defined Benefit Supplement account. Your Defined Benefit account contains your member contributions

on service credit earned for working up to one year in a school year. Any contributions on earnings in excess of one year of service credit go into your Defined Benefit Supplement account. When you take a Defined Benefit and Defined Benefit Supplement refund, you terminate your membership with CalSTRS and forfeit your rights to all CalSTRS benefits. CalSTRS cannot issue a partial Defined Benefit or Defined Benefit Supplement refund.

Employment Termination: Before applying for a refund, you must terminate all CalSTRS-covered employment in the California public school system with either an action by you as the employee, such as employment resignation, or action by your employer, such as dismissal or layoff.

Substitute teaching, including part-time substituting, qualifies as employment and must be terminated in order to receive a refund.

Payment Time Frame: Your Defined Benefit refund may be processed in two phases. The initial payment will include contributions and interest posted to your account as of the date your refund was processed. If additional contributions and interest are posted to your account after the initial payment is issued, CalSTRS will issue a second payment approximately four months later.

Your Defined Benefit Supplement refund, or termination benefit, may be paid at a later date than your Defined Benefit refund. Current law prohibits CalSTRS from distributing your Defined Benefit Supplement Termination Benefit until six months after your employment termination date. Defined Benefit Supplement funds continue to earn interest while they remain in your Defined Benefit Supplement account. If you return to CalSTRS-covered employment within the six-month waiting period, you are not eligible for a Defined Benefit Supplement Termination Benefit.

By law, CalSTRS cannot distribute more than one Defined Benefit Supplement Termination Benefit to a member within a five-year period. If you apply for a Defined Benefit Supplement Termination Benefit within five years of your last Defined Benefit Supplement Termination Benefit payment, CalSTRS cannot process your request until five years have passed.

Cancellation of a Refund: You may cancel your refund if you return the Defined Benefit and Defined Benefit Supplement funds in full (gross amount) to CalSTRS within 30 days of the payment issue date. You must also send CalSTRS a written request to cancel your refund.

COMPLETING THE REFUND APPLICATION

Fill out your application in black or blue ink and keep a copy for your records. If the information is not correct and legible, your refund payments will be delayed and your application will be returned to you for correction. If you make a mistake completing the application, line through the error, make your correction and initial the change.

We receive many applications, which we process in the order they were received, so be sure to review the Refund Application Checklist before submitting your application.

You may be eligible to complete and submit your application online using myCalSTRS for faster processing. See page 3 to learn more.

CalSTRS Pension2® Rollovers: If you select Pension2 for your rollover, we will obtain the required signatures on your behalf. If you already have a Pension2 account, we will roll over your funds to that account. If you do not have a Pension2 account, we will open a Pension2 403(b) account for you and your investment will be defaulted into Voya Fixed Plus III, a fixed investment that guarantees your principal and a specific interest rate. You can reallocate your investment at any time. For more information or to enroll right now, visit Pension2.com or call toll free 888-394-2060.

SECTION 1: MEMBER INFORMATION

Enter your full name as it appears on your Social Security card, Client ID or Social Security number, complete mailing address, date of birth, telephone number and email address.

If you’ve had a name change, complete the Request for Name Change form, available at CalSTRS.com/forms, and submit it with your application.

SECTION 2: COUNTY OF EMPLOYMENT

List the county in California in which you were employed and your last day of employment.

SECTION 3: EMPLOYER CERTIFICATION OF

EMPLOYMENT TERMINATION

Terminated Work Within the Last 12 Months?

This section must be completed by your employer if you were employed within the last 12 months. If you were employed by more than one employer in the last

12 months, you must submit a separate completed page 1 of the Refund Application certified by each employer.

If you terminated employment within the last 12 months, send your application to your county office of education for certification by the superintendent or authorized designee before submitting it to CalSTRS. For the following employers, send your application as instructed:

Los Angeles Community College District: Send to the

Retirement Division of the individual college.

Los Angeles County Office of Education: Send to 9300 East Imperial Highway, Room 132, Downey, CA 90242.

Los Angeles Unified School District: Send to the Accounting & Disbursements Division, Payroll Services Branch (ATTN: Refund Application), P.O. Box 513307, Terminal Annex, Los Angeles, CA 90051-1307.

San Bernardino County Superintendent of Schools:

Send to 760 E. Brier Drive, San Bernardino, CA 92408.

San Diego County Office of Education: Send to Retirement Reporting, Room 605, 6401 Linda Vista Road, San Diego, CA 92111-7319.

San Francisco Community College District: Send to the

Retirement Division of the individual college.

Stanislaus County Office of Education: Send to 1100 H

Street, Modesto, CA 95354.

SECTION 4: DEFINED BENEFIT PAYMENT INSTRUCTIONS

Read Special Tax Notice: Your Rollover Options on pages 4–7.

Tax-deferred funds are subject to tax withholding while after-tax funds are not. See your Retirement Progress Report to find out if you have both tax-deferred and after-tax (taxed) contributions.

4.1Defined Benefit Refund Election: Elect a direct payment or rollover to another qualified plan with a financial institution.

4.2Defined Benefit Rollover: If you elect a rollover (trustee-to-trustee transfer) of your Defined Benefit funds, this section must be completed. If you elect to roll over less than the full amount of your Defined Benefit account, the remaining balance will be distributed directly to you, with applicable taxes withheld, at the address listed in Section 1.

Your account balance must be $200 or more to qualify for a rollover to a financial institution.

Financial Institution Information

If you’re rolling over your Defined Benefit funds to another qualified plan with a financial institution other than CalSTRS Pension2, you must get a signature from your financial institution to verify the information is accurate before submitting your application. If the information is not complete or correct, your rollover will be delayed. CalSTRS is not able to process rollovers to financial institutions outside the U.S.

SECTION 5: DEFINED BENEFIT SUPPLEMENT

PAYMENT INSTRUCTIONS

Read Special Tax Notice: Your Rollover Options on pages 4–7.

5.1Defined Benefit Supplement Termination Benefit Election: Elect a direct payment or a rollover to a financial institution.

5.2Defined Benefit Supplement Rollover: If you elect a rollover (trustee-to-trustee transfer) of your Defined Benefit Supplement funds, this section must be completed. If you elect to roll over less than the full amount of your Defined Benefit Supplement account, the remaining balance will be distributed directly to you, with applicable taxes withheld, at the address listed in Section 1.

Your account balance must be $200 or more to qualify for a rollover to a financial institution.

Financial Institution Information: If you’re rolling over your Defined Benefit Supplement funds to another qualified plan with a financial institution other than CalSTRS Pension2, you must get a signature from your financial institution to verify the information is accurate before submitting your application. If the information is not complete or correct, your rollover will be delayed. CalSTRS is not able to process rollovers to financial institutions outside the U.S.

SECTION 6: TAX WITHHOLDING PREFERENCES

CalSTRS is required to withhold 20 percent federal tax on all payments distributed directly to you. We will withhold

2 percent California state tax if your address is in California unless you elect to not have state tax withheld.

Addresses Outside California: In compliance with federal law, California doesn’t tax the CalSTRS benefits of nonresidents. If you think you may be liable for California state income tax, complete Section 6 to request California state income tax withholding. CalSTRS does not withhold income tax for states other than California.

CalSTRS may be required to withhold federal income tax from distributions mailed to a foreign country.

After-tax contributions are not taxable but are eligible for rollover. All interest is taxable and is eligible for rollover. Separate payments will be issued for the taxable and nontaxable portions of the distribution.

NOTE: CalSTRS does not roll over or withhold federal or state income tax from refunds that are less than $200.

SECTION 7: REQUIRED SIGNATURES

Check all boxes that apply, then sign and date your Refund Application. If you are married or registered as a domestic partner, your spouse or partner also must sign and date your application. Your signature date is the date you signed your application. Your signature date must be within six months of the date CalSTRS receives your application.

If your spouse or registered domestic partner does not sign your application, you must include a completed and signed Justification for Non-Signature of Spouse or Registered Domestic Partner form with your application.

Electronic signatures other than those generated through myCalSTRS will not be accepted.

If you divorced or terminated a registered domestic partnership and a portion of your CalSTRS benefits was awarded to a former spouse or partner, check the box that indicates this. You may need to refer to your settlement agreement to make this determination. In addition, if your court documents have not been reviewed by CalSTRS, you may be asked to provide them later.

SPECIAL TAX NOTICE: YOUR ROLLOVER OPTIONS

You are receiving this notice because all or a portion of your CalSTRS payment is eligible to be rolled over to a qualified IRA or an eligible employer plan. Read this notice to help you decide whether to do a rollover.

SUBMITTING YOUR APPLICATION

Terminated Work Within the Last 12 Months?

See Section 3 of the Instructions.

Terminated Work More Than 12 Months Ago or Refund Applications With Required Certification?

If you terminated employment more than 12 months ago or your Refund Application has been certified and you are ready to submit it to CalSTRS:

Mailing Address

CalSTRS

P.O. Box 15275, MS 65

Sacramento, CA 95851-0275

Overnight

If you are using a special mailing service such as UPS or FedEx, send your application to:

CalSTRS Member Services

100 Waterfront Place

West Sacramento, CA 95605

Hand Delivery

Hand deliver your application to a local CalSTRS office. See CalSTRS.com/forms-drop for a current listing.

Fax Delivery

916-414-5964

QUESTIONS

Email your questions using your myCalSTRS account or at CalSTRS.com/contact, or call 800-228-5453.

If you select a rollover to CalSTRS Pension2 or a direct payment and haven’t worked in a CalSTRS-covered position within the past 12 months, you can complete and submit your application online using myCalSTRS for faster processing. Go to myCalSTRS (click on Services, then Complete & Submit Forms, then Refund Your Contributions). Not registered yet? Complete the one-time registration process at myCalSTRS.com. Your spouse or registered domestic partner will be directed to register for a myCalSTRS account and submit an electronic signature.

INTRODUCTION

You are receiving this notice because all or a portion of your CalSTRS Defined Benefit Supplement, Defined Benefit refund or Cash Balance payment may be eligible for a rollover to an IRA or another eligible employer plan. This notice is intended to help you decide whether to do such a rollover.

Rules that apply to most CalSTRS payments 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.

The following summarizes tax information and is provided in accordance with Section 402(f) of the Internal Revenue Code. CalSTRS does not provide tax information or advice. Consult a tax professional, the Internal Revenue Service or the State Franchise Tax Board for specific information and to confirm that any relevant tax laws have not changed since this notice was released.

Certain California tax information is also provided. In general, California law conforms to federal tax law. However, there are some differences between California and federal law. In addition, if you do not meet California residency criteria, your CalSTRS benefits are not subject to state income tax. For additional information, visit ftb.ca.gov.

30-Day Notice Period and Your Right to Waive Generally, CalSTRS cannot make a direct rollover or a payment to you until at least 30 days after you receive this notice. If you do not wish to wait until this 30-day notice period ends before your payment is processed, you may waive the notice period.

GENERAL INFORMATION ABOUT ROLLOVERS

How can a rollover affect my taxes?

You will be taxed on your CalSTRS payment if you do not roll it over. If you are under age 591/2 and do not do a rollover, you also will have to pay a 10 percent additional federal income tax and a 2.5 percent additional California state income tax on early distributions, unless an exception applies.

If you do a rollover, however, you will not have to pay tax until you receive distributions later and the 10 percent additional federal income tax and 2.5 percent additional state income tax will not apply if those distributions are made after you are age 591/2, or if an exception applies.

Where may I roll over my CalSTRS payment?

You may roll over the payment to either an IRA (an individual retirement account or individual retirement annuity) or another eligible employer plan (a tax-qualified plan, 403(b) plan or 457(b) plan) that will accept the rollover. The rules

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of the IRA or 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. You can choose either a direct rollover or a 60-day rollover.

Direct rollover: If you do a direct rollover, CalSTRS will make the payment directly to your IRA or another eligible employer plan. You should contact the IRA sponsor or the administrator of the plan for information on how to do a direct rollover.

If you do a direct rollover of only a portion of your CalSTRS payment and a portion is paid to you at the same time, the portion directly rolled over consists first of the amount that would be taxable if not rolled over.

60-day rollover: If you do not do a direct rollover, you still may do a rollover by making a deposit into an IRA or eligible employer plan that will accept it. You will have 60 days after you receive your CalSTRS payment to make the deposit.

If you do not do a direct rollover, CalSTRS is required to withhold 20 percent of the payment for federal income taxes. Unless you elect to not have state tax withheld or you are a nonresident of California, CalSTRS will withhold at 2 percent. 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 percent withheld for federal taxes and any state tax withheld. If you do not roll over the entire amount of the payment, the portion not rolled over will be taxed in the year distributed and will be subject to the 10 percent additional federal income tax and the 2.5 percent additional state income tax on early distributions if you are under age 591/2, unless 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 eligible for rollover. Any CalSTRS payment is eligible for rollover, except:

•Benefit payments spread over a period of at least 10 years or over your life or life expectancy (or the lives or joint life expectancy of you and your beneficiary).

•Required minimum distributions in the calendar year in which you turn age 70½ (or after death).

•Corrective distributions of contributions that exceed tax law limitations.

CalSTRS 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 percent additional federal income tax and the 2.5 percent additional state income tax on early distributions?

If you are under age 591/2, you will have to pay the

10 percent additional federal income tax and 2.5 percent additional state income tax on early distributions for any CalSTRS payment, including amounts withheld for income tax, that you do not roll over, unless one of the exceptions listed below applies. This tax applies to the part of the distribution that you must include in income and is in addition to the regular federal and state income taxes on the payment not rolled over.

The 10 percent additional federal income tax and the

2.5percent additional state income tax do not apply to the following CalSTRS payments:

•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 expectancy of you and your beneficiary).

•Payments made due to disability.

•Payments after your death.

•Corrective distributions of contributions that exceed tax law limitations.

•Payments made directly to the government to satisfy a federal tax levy.

•Payments made under a qualified domestic relations order (QDRO).

•Payments up to the amount of your deductible

medical expenses whether or not you itemize deductions for the taxable year.

•Payments for certain distributions related to certain federally declared disasters.

If I do a rollover to an IRA, will the 10 percent additional federal income tax and the 2.5 percent additional state income tax apply to early distributions from the IRA? If you receive a payment from an IRA when you are under age 591/2, you will have to pay the 10 percent additional federal income tax and 2.5 percent additional state income tax on the part of the distribution that you must include in income unless an exception applies. In general, the exceptions to the additional federal and state income taxes 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:

•The exception for payments made after you separate from service if you will be at least age 55 in the year of the separation does not apply.

•The exception for qualified domestic relations orders does not apply. However, a special rule applies under which, as part of a divorce or separation agreement, a tax-free transfer may be made directly to an IRA of a spouse or former spouse.

•The exception for payments made at least annually in equal or close to equal amounts over a specified period applies without regard to whether you have had a separation from service.

•There are additional exceptions for (1) payments for qualified higher education expenses, (2) payments up to $10,000 used in a qualified first-time home purchase, and (3) payments for health insurance premiums after you have received unemployment compensation for 12 consecutive weeks (or would have been eligible to receive unemployment compensation but for self-employed status).

SPECIAL RULES AND OPTIONS

If Your Payment Includes After-Tax Contributions After-tax contributions included in your payment are not taxed upon distribution. 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 separate account, a special rule may apply to determine whether the after-tax contributions are included in a payment. In addition, special rules apply when you do a rollover, as described below.

You may roll over to an IRA a payment that includes after- tax contributions 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 your CalSTRS payment and 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 example, assume you are receiving a distribution of $12,000, of which $2,000 is after- tax contributions. 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 being after-tax contributions. If you do a direct rollover of your entire CalSTRS payment 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 eligible employer plan all of a payment that includes after-tax contributions, but only through a direct rollover—and only if the receiving plan separately accounts for after-tax contributions and is not a governmental section 457(b) plan. You can do a 60-day rollover to an eligible employer plan of part of a CalSTRS 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 authority to waive the deadline under certain extraordinary circumstances, such as when external events prevented you from completing the rollover by the 60-day rollover deadline.

Under certain circumstances, you may claim eligibility for a waiver of the 60-day rollover deadline by making a written self-certification. Otherwise, to apply for a waiver from the IRS, you must file a private letter ruling request with the IRS. Private letter ruling requests require the payment of a nonrefundable user fee. For more information, see IRS Publication 590-A, Contributions to Individual Retirement Arrangements.

If You Were Born On or Before January 1, 1936

If you were born on or before January 1, 1936, and receive a lump-sum distribution that you do not roll over, special rules for calculating the amount of the tax on the payment might apply to you. For more information, see IRS Publication 575, Pension and Annuity Income.

If You Roll Over Your Payment to a Roth IRA

If you roll over your CalSTRS 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 percent additional income tax and 2.5 percent additional state income tax on early distributions will not apply (unless you take the amount rolled over out of the Roth IRA within five 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 qualified distribution from a Roth IRA is a payment made after you are age 591/2—or after your death or disability, or as a qualified first-time homebuyer distribution of up to $10,000—and after you have had a Roth IRA for at least five years. In applying this five-year rule, 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 taxed to the extent of earnings after the rollover, including the 10 percent additional federal income tax and 2.5 percent additional state income tax on

early distributions, unless an exception applies. You do not have to take required minimum distributions from a Roth IRA during your lifetime. For more information, see IRS Publications 590-A, Contributions to Individual Retirement Arrangements and 590-B, Distributions From Individual Retirement Arrangements.

CalSTRS is not responsible for assuring your eligibility to make a rollover to a Roth IRA. Consult your tax adviser if you are interested in rolling over your payment to a Roth IRA.

If You Are Not a CalSTRS Member

Payments after a member’s death. If you receive a distribution after a CalSTRS member’s death that you do not roll over, the distribution will generally be taxed in the same manner described elsewhere in this notice. However, the

10 percent additional federal income tax and 2.5 percent additional state income tax on early distributions do not apply. The special rule described under the section “If you were born on or before January 1, 1936” applies only if the CalSTRS member was born on or before January 1, 1936.

If you are a surviving spouse. If you receive a CalSTRS payment as the surviving spouse of a deceased member, you have the same rollover options that the member would have had, as described elsewhere in this notice. In addition, if you choose to do a rollover 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 591/2 will be subject to the 10 percent additional federal income tax and 2.5 percent additional state income tax on early distributions, unless an exception applies. In addition, required minimum distributions from your IRA do not have to start until after you are age 701/2.

If you treat the IRA as an inherited IRA, payments from the IRA will not be subject to the 10 percent additional federal income tax and 2.5 percent additional state income tax on early distributions. However, if the member had started taking required minimum distributions, you will have to receive required minimum distributions from the inherited IRA. If the member had not started taking required minimum distributions, you will not have to start receiving required minimum distributions from the inherited IRA until the year the member would have been age 701/2.

If you are a surviving beneficiary other than a spouse.

If you receive a CalSTRS payment because of the member’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 percent additional federal income tax and 2.5 percent additional state income tax on early distributions. You will have to receive required minimum distributions from the inherited IRA.

Payments under a qualified domestic relations order. If you are the spouse or former spouse of a CalSTRS member who receives a payment from CalSTRS under a qualified domestic relations order (QDRO), you generally have the same options and the same tax treatment that the member would have (for example, you may roll over the payment to your own IRA or an eligible employer plan that will accept it). However, payments under the QDRO will not be subject to the 10 percent additional federal income tax or 2.5 percent additional state income tax on early distributions.

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 a U.S. eligible employer plan, CalSTRS is generally required to withhold 30 percent of the payment for federal income taxes. If the amount withheld exceeds the amount of tax you owe (as may happen if you do a 60-day rollover), you may request an income tax refund by filing IRS Form 1040NR and attaching your IRS 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, IRS Publication 515, Withholding of Tax on Nonresident Aliens and Foreign Entities, and FTB Publication 1100, Taxation of Nonresidents and Individuals Who Change Residency.

OTHER SPECIAL RULES

If a payment is one in a series of payments for less than

10 years, your choice 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, CalSTRS is not required to allow you to do a direct rollover and is not required to withhold federal income taxes. However, you may do a 60-day rollover.

When electing how to receive a CalSTRS payment that is rollover eligible, any amount not designated for rollover will be issued directly to you according to the payment preference on file for your account.

You may have special rollover rights if you recently served in the U.S. Armed Forces. For more information, see IRS Publication 3, Armed Forces’ Tax Guide. You also may have special rollover rights if you were affected by a federally declared disaster or similar event, or if you received a distribution on account of a disaster. For more information, visit irs.gov.

FOR MORE INFORMATION

See the Tax Considerations for Rollovers booklet at CalSTRS.com. You should also consult a professional tax adviser before taking a payment from CalSTRS.

In addition, you will find more information on the federal tax treatment of payments from employer plans in IRS

Publications 575, Pension and Annuity Income, Publication 590-A, Contributions to Individual Retirement Arrangements, 590-B, Distributions From Individual Retirement Arrangements, and Publication 571, Tax-Sheltered Annuity Plans (403(b) Plans). These publications are available from a local IRS office, at irs.gov, or by calling 800-TAX-FORM (800-829-3676).

For information on state tax, contact the California Franchise Tax Board at ftb.ca.gov or call 800-852-5711 (or 916-845-6500 if calling from outside the U.S.). Also see FTB Publication 1005, Pension and Annuity Guidelines.

RIGHT TO RECEIVE PAPER DOCUMENT

Contact CalSTRS to receive this Special Tax Notice:

Your Rollover Options provided as a written paper document at no charge.

RIGHT TO WITHDRAW YOUR CONSENT

You have the right to withdraw consent to receive electronic delivery of the Special Tax Notice: Your Rollover Options at any time. Withdrawal of your consent may delay processing of your application. If you would like to withdraw your consent to receive electronic delivery of the Special Tax Notice: Your Rollover Options, contact CalSTRS and request to receive this notice and application as a written paper document at no charge.

Scope of Your Consent – Consent to receive electronic delivery of the Special Tax Notice: Your Rollover Options applies only to the particular transaction.

CalSTRS Contact Procedures – If you have questions about the procedures for receiving a written paper document or to update your electronic information, contact CalSTRS at 800-228-5453, CalSTRS.com/contactus or 916-414-5040 (fax).

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Use Adobe® Reader® to view, print and save this notice and other CalSTRS important online documents. If you do not have Adobe Reader installed on your computer, you may download the free program from the Adobe website.

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Refund Application

RF1360 rev 01/19

California State Teachers’ Retirement System

P.O.Box 15275, MS 65

Sacramento, CA 95851-0275

800-228-5453

CalSTRS.com

Select one:

Other eligible plan such as 403(b), 457(b), 401(k) or 401(a)

Select one:

Percentage to Transfer (1–100%): _____________%

Select one:

Select one:

Other eligible plan such as 403(b), 457(b), 401(k) or 401(a)

Select one:

Other eligible plan such as 403(b), 457(b), 401(k) or 401(a)

Select one:

Percentage to Transfer (1–100%): _____________%

Select one:

Other eligible plan such as 403(b), 457(b), 401(k) or 401(a)

Select one:

Percentage to Transfer (1–100%):_____________%

Withhold California state income tax?

Yes

No

Withhold California state income tax?

Yes

No