Transcription of Form 5C: Rollover Distribution Election
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Form 5C: Rollover Distribution Election
Public Employees retirement System of Mississippi 429 Mississippi Street, Jackson, MS 39201-1005 , fax Rollover Distribution Election form 5C Revised 03/14/2022 Please print or type in black ink. Completed form should be mailed or faxed to PERS and must accompany form 5 or form 5D, as applicable. See bottom of form for contact information. Applicant Information First Name: _____ MI: _____ Last Name: _____ Social Security No.: _____ Member Beneficiary of Deceased Member: Spouse Non-Spouse Mailing Address: _____ City: _____ State: _____ Zip: _____ Phone: _____ Cellular Home Work E-Mail: _____ retirement Plan Plans are governmental defined benefit plans qualified under Section 401(a) of the Internal Revenue Code.
Public Employees’ Retirement System of Mississippi 429 Mississippi Street, Jackson, MS 39201-1005 800.444.7377 601.359.3589 601.359.5261, fax www.pers.ms.gov Rollover Distribution Election Form 5C – Revised 03/18/2020 Please print or type in black ink.
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