At the core of managing one's retirement and financial future after departing from public service is the understanding and completion of necessary documentation, such as the Lacera Rsd 562 form. Designed for individuals who have terminated their service with Los Angeles County, this comprehensive document serves a critical role in the process of withdrawing retirement contributions. The form meticulously outlines options available to former employees, including the choice of receiving contributions directly or opting for a rollover into an IRA or another employer's qualified plan. Crucially, it highlights the financial implications of each choice, such as mandatory federal income tax withholdings that apply if the taxable portion of contributions is not fully rolled over. Additionally, it guides applicants through the necessary declarations and authorization steps, underscoring the importance of understanding the rights relinquished upon withdrawal, especially concerning future retirement benefits from the Los Angeles County Employees Retirement Association (LACERA). This form not only represents a key step in managing one's post-service financial path but also emphasizes the importance of informed decision-making and precise compliance with procedural requirements.
| Question | Answer |
|---|---|
| Form Name | Lacera Rsd 562 Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | lacera withdrawal form, apply for lacera retirement, lacera business, lacera |
Los Angeles County Em ployees Retirem ent Association
300 N . Lake Ave., Pasadena, CA 91101 ■ M ail to: PO Box 7060, Pasadena, CA |
626/ |
WITHDRAWAL APPLICATION |
A |
Please type or print legibly. |
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SECTION I – TERMINATION OF COUNTY SERVICE |
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On ______________, I terminated service with the following department: ___________________________________________,
Date
and I am no longer employed by Los Angeles County.
Print Name _____________________________________________________________________________________________________
FirstMiddleLast
Home Address __________________________________________________________________________________________________
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Street |
City |
State |
ZIP |
Social Security # _________ - ______ - ___________ Employee # _____________________ |
Department # ________________ |
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Work Phone ( |
) _____________________________ |
Home Phone ( |
) ___________________________________ |
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SECTION II – WITHDRAWAL (with or without a rollover)
You may request your contributions be paid directly to you. Or, you may request that the taxable portion of your contribu- tions, plus interest, be rolled over to an IRA or another employer's qualified plan. If your contributions are paid directly to you, or if you roll over less than 100% of the taxable portion of your contributions, LACERA must deduct 20% for manda- tory federal income tax withholding; the balance will be refunded to you. If the entire taxable portion is not rolled over into an IRA or other employer's qualified plan within 60 days after you receive it, you may owe tax penalties in addition to the 20% withheld. You may request that LACERA withhold state tax by indicating a percentage or specified amount below; or you may pay directly to the State Franchise Tax Board when you file your income taxes for the year. Nontaxable contribu- tions, if any, will be refunded to you.
Check the box es that apply to you, then read and complete Section III.
1.
2.
I request to withdraw my contributions, plus interest, and have them paid directly to me. I also request LACERA
withhold state tax at: |
2% or |
_____% or |
$________________ specified amount |
None |
I request to roll over |
100% or |
_____% of the taxable portion of my contributions, plus interest, to: |
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3.
Name of IRA Institution |
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IRA Account Number (not Social Security number) |
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Address of IRA Institution |
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City |
State |
ZIP |
I request to roll over |
100% or |
_____% of the taxable portion of my contributions, plus interest, to the |
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following employer’s qualified plan:
Name of Plan
Name of Employer
Address of Employer |
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State |
ZIP |
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Name of Trustee |
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Address of Trustee |
City |
State |
ZIP |
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Plan/ Trust EIN (Employer Identification Number) |
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(OVER)
RSD 562 (9/ 00)
SECTION III – AUTHORIZATION
I have read and understand all materials included with this form. I understand that:
•IF I CHOOSE A WITHDRAWAL, I LOSE ALL RIGHTS TO FUTURE RETIREMENT BENEFITS FROM LACERA, INCLUDING DISABILITY BENEFITS.
•If I have requested that the taxable portion of my contributions, plus interest, be rolled over into an IRA or another employer’s qualified plan, I will receive a check made payable to the institution named in Section II. It is my responsibil- ity to deposit it with the appropriate institution. I understand that LACERA will not verify that the information provid- ed is correct. It is my responsibility to provide accurate information and to verify that the IRA institution or other employer’s plan is qualified to accept a rollover.
•If I choose to have a withdrawal paid directly to me, or roll over less than 100% of the taxable portion of my contribu- tions plus interest, LACERA will withhold 20% of the taxable portion for federal income taxes.
If you are requesting a w ithdraw al paid directly to you, or a rollover, you must sign this form in the presence of an authorized LACERA representative or a N otary Public.
_____________________________________________________________________________________________
Your SignatureD ate
____________________________________________________________________________________________________________________
Authorized LACERA Representative |
D ate |
THIS FORM MUST BE NOTARIZED BEFORE RETURNING TO LACERA
State of _____________________________________________________
County of ___________________________________________________
On _____________________, before me the undersigned, a Notary Public, personally appeared.
Month/ Day/ Year
Name(s) of Signer(s)_______________________________________________________________________________________,
❑personally known to me - OR - ❑ proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/ are subscribed to the within instrument and acknowledged to me that he/ she/ they executed the same in his/ her/ their authorized capacity(ies), and that by his/ her/ their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
My commission expires _____________________
Date |
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WITN ESS my hand and official seal. |
S.S. |
Signature of Notary Public