Form 5C: Rollover Distribution Election

1 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.

2 Select applicable plan. Public Employees retirement System of Mississippi (PERS) Mississippi Highway Safety Patrol retirement System (MHSPRS) Supplemental Legislative retirement Plan (SLRP) Municipal retirement Systems (MRS) City: _____ Rollover Distribution Payment Selection Select one. If you have any questions or do not understand the provisions of either federal or state tax laws, please contact the Internal Revenue Service (IRS), the Mississippi Department of Revenue, or a tax professional for advice. I elect to have the refund paid in the following manner: A.

3 ____ 100% Direct Rollover /Transfer of Taxable Distribution * PERS is directed to mail the taxable portion of my Distribution to the trustee/custodian who has signed the Agreement of Trustee/Custodian. The non-taxable Distribution , if any, should be mailed directly to me. B. ____ 100% Direct Rollover /Transfer of Taxable and Non-Taxable Distributions PERS is directed to mail the taxable and non-taxable portions of my Distribution to the trustee/custodian who has signed the Agreement of Trustee/Custodian and has agreed to separately account for the taxable and non-taxable portions of the Rollover .

4 C. ____ Partial Direct Rollover /Transfer of Taxable Distribution * PERS is directed to mail $_____ of my taxable Distribution to the trustee/custodian who has signed the Agreement of Trustee/Custodian. The remainder of the taxable Distribution , less the mandatory 20% federal withholding tax, plus the non-taxable Distribution , if any, should be mailed directly to me. I understand that this mandatory withholding may not represent my actual tax liability and that this payment may be subject to an additional federal tax equal to 10% of the taxable portion if the payment is received after separation from service but before age 55 or if the payment is received before age 50 for a public safety employee (any employee of a state or political subdivision who provides police protection, firefighter services, or emergency medical services).

5 To withhold additional federal taxes, please complete IRS form W-4R. D. ____ Partial Direct Rollover /Transfer of Taxable and Non-Taxable Distributions PERS is directed to mail $_____ of my taxable Distribution and $_____ of my non-taxable Distribution to the trustee/custodian who has signed the Agreement of Trustee/Custodian and has agreed to separately account for the taxable and non-taxable portions of the Rollover . The remainder of the taxable Distribution , less the mandatory 20% federal withholding tax, plus the remainder of the non-taxable Distribution , if any, should be mailed directly to me.

6 I understand that this mandatory withholding may not represent my actual tax liability and that this payment may be subject to an additional federal tax equal to 10% of the taxable portion if the payment is received after separation from service but before age 55 or if the payment is received before age 50 for a public safety employee (any employee of a state or political subdivision who provides police protection, firefighter services, or emergency medical services). To withhold additional federal taxes, please complete IRS form W-4R.

7 Applicant Authorization I acknowledge that I have read the Special Tax Notice Regarding Plan Payments. If an authorized representative signs this form , attach a copy of the durable power of attorney, conservatorship or guardianship papers, or other legal documents as proof of authority to sign this form . Applicant s Signature: _____ Date mm/dd/ccyy:_____ Trustee/Custodian to Accept Rollover Agreement The transfer/acceptance letter of your trustee/custodian will not be accepted in lieu of this form . Trustee/Custodian Name: _____ Federal Tax ID: _____ Mailing Address (Leave blank if check is to be mailed directly to applicant): _____ City: _____ State: _____ Zip: _____ Phone: _____ Rollover Account Number: _____ Rollover Account is an inherited or beneficiary account Rollover Account Type: 401(a) Qualified Plan 401(k) Qualified Plan 403(a) Qualified Annuity 403(b) TSA 408(b) IRA Annuity Select one.

8 Traditional IRA ROTH IRA SEP IRA *457(b) Def. Comp. (A & C only) * Surviving non-spouse is not eligible for this Rollover . Trustee/Custodian s Signature: _____ Date mm/dd/ccyy: _____ Page 1 of 4 Public Employees retirement System of Mississippi 429 Mississippi Street, Jackson, MS 39201-1005 , fax Special Tax Notice Regarding Plan Payments Your Rollover Options You are receiving this notice because all or a portion of a payment you are receiving from the Public Employees retirement System of Mississippi (the Plan) is eligible to be rolled over to an IRA or an employer plan.

9 This notice is intended to help you decide whether to do such a Rollover . This notice describes the Rollover rules that apply to payments from the Plan that are not from a designated Roth account (a type of account with special tax rules in some employer plans). If you also receive a payment from a designated Roth account in the Plan, you will be provided a different notice for that payment, and the Plan administrator or the payor will tell you the amount that is being paid from each account. Rules that apply to most payments from a plan are described in the General Information about rollovers section.

10 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 59 and do not do a Rollover , you also will have to pay a 10% additional income tax on early distributions (unless an exception applies). However, if you do a Rollover , you will not have to pay tax until you receive payments later and the 10% additional income tax will not apply if those payments are made after you are age 59 (or if an exception applies).