REFUND/ROLLOVER REQUEST
T E R M I N A T I N G P E R A - C O V E R E D E M P L O Y M E N T
I N C L U D E S T H E C O L O R A D O P E R A F O R M S T O
C L O S E Y O U R P E R A D E F I N E D B E N E F I T A C C O U N T
Revised August 2016

CONTENTS
OVERVIEW
Read this booklet before completing a Rollover
Part I: Terminating
Request—Defined Benefit Plan or Refund Request—
PERA-Covered Employment ........................1
Defined Benefit Plan form to do a rollover/refund of
What You Should Know Before Rolling
your Colorado PERA Defined Benefit (DB)
Over or Refunding Your PERA DB
Plan account(s).
Plan Account(s) ........................................... 1
Rolling Over or Refunding Your PERA
For a quick summary of what you will lose by
DB Plan Account(s) .....................................3
withdrawing your account and what you can gain
Part II: IRS Notice for Qualified
by leaving your money at PERA, see page 10.
Distributions from Your PERA
401(a) DB Plan Account(s) ............................5
This booklet explains the PERA benefits and rights
Notice Summary .........................................6
you will forfeit if you do a rollover/refund of your
DB Plan account(s), as well as the details of taxes
Take a Second Look .....................................10
you may incur as a result of your decision to do a
Rollover Request—Defined Benefit
rollover/refund of your DB Plan account(s). Do not
Plan Form Section ........................................ 11
use this booklet or forms to roll over or withdraw
Information About the Rollover
your PERAPlus 401(k), PERAPlus 457, or PERA DC
Request—Defined Benefit Plan Form ....12
Plan accounts.
Completing the Rollover Request—
Defined Benefit Plan Form ..................12
Si usted quiere una copia de este folleto en español,
Processing Time for the Rollover
llame al 1-800-759-7372.
Request—Defined Benefit Plan Form ..12
Rollover Request—Defined Benefit
Plan Form ...................................................13
Refund Request—Defined Benefit Plan
Form Section .................................................17
Information About the Refund Request—
Defined Benefit Plan Form ......................18
Completing the Refund Request—
Defined Benefit Plan Form ..................18
Processing Time for the Refund
Request—Defined Benefit
Plan Form ................................................18
Refund Request—Defined Benefit
Plan Form ...................................................19
B

3% If you leave your DB Plan account(s) at PERA, it will continue to earn interest. The current interest rate is
3 percent compounded annually.
PART I: TERMINATING
WHAT YOU SHOULD KNOW BEFORE
ROLLING OVER OR REFUNDING YOUR
PERA-COVERED
PERA DB PLAN ACCOUNT(S)

» Your PERA DB Plan account(s) is a retirement
EMPLOYMENT
account(s) for future retirement income. If you do a
rollover/refund of your DB Plan account(s) now, you
will not have a retirement benefit in the future for the
When you terminate PERA-covered employment, you
time you worked for a PERA employer.
will need to decide whether to leave your PERA 401(a)
DB Plan account(s) at PERA, roll it over to an IRA or

» You may leave your DB Plan account(s) at PERA
eligible employer plan, or refund it. In this section, we
where it will continue to earn interest. The interest
will provide you with information to help you make
rate is set by the PERA Board and is subject to change
this decision.
annually. The current interest rate is 3 percent
compounded annually.
As a result of the Denver Public Schools Retirement
» You may roll over your DB Plan account(s) to
System (DPSRS) merger with PERA, you may have two
another eligible plan and keep your account(s)
DB Plan accounts with PERA—one under the PERA
dedicated for retirement.
benefit structure and one under the Denver Public
Schools (DPS) benefit structure. If you do a rollover/

» You may refund your DB Plan account(s) and pay
refund of your DB Plan accounts, you must do a
income taxes and the IRS 10 percent additional
rollover/refund of both DB Plan accounts unless you
income tax for early distribution if you refund before
are eligible to retire from one or both benefit structures
age 59½.
and choose to take a benefit.

» If you return to work for a PERA employer before
your rollover/refund is issued, your rollover/refund
will be canceled.

» If you are under age 55 and working for any PERA
employer, you must terminate employment with
all PERA employers, including those that offer an
Optional Retirement Plan (ORP), to be eligible for a
rollover/refund.
1

IF YOU LEAVE YOUR PERA AND/OR DPS BENEFIT

» If you choose to receive a monthly benefit in the future,
STRUCTURE DB PLAN ACCOUNT(S) AT PERA
you have the option to enroll in the PERACare Health

» You will retain the rights associated with your PERA
Benefits Program and may receive a subsidy toward
membership and if you return to PERA membership,
your health care premium.
continue to earn service credit.

» If you have 25 or more years of service credit, you may

» You may continue coverage in the PERA life insurance
be eligible for a monthly benefit that is indexed
program (if already enrolled) at the same low
(increased) based on the annual increase provisions of
group rate by setting up an automatic direct pay
your plan if you began PERA membership on or before
arrangement with Unum.
December 31, 2006, and you were eligible to retire on
January 1, 2011. If you meet these qualifications, you

» You may consider applying for PERA’s disability
should contact PERA’s Customer Service Center for
program rather than doing a rollover/refund, if you
additional information.
have more than five years of service credit and are
terminating PERA-covered employment because of a
IF YOU LEAVE YOUR DPS BENEFIT STRUCTURE DB
potentially disabling condition.
PLAN ACCOUNT AT PERA


» When you are eligible for retirement (see the
See the Colorado PERA Disability
Colorado PERA Retirement Eligibility fact sheet on the
Program booklet for more information.
PERA website), you may apply for a benefit, roll over,
or refund your DB Plan account. If you do a rollover/
refund of your DB Plan account, you will receive, at

» Please contact PERA whenever your address changes
time of rollover/refund, a 100 percent match equal
or once every five years. If you do not have five
to your member contributions and interest if you
years of service credit, your DB Plan account(s) may
terminated employment on or after January 1, 2001,
be turned over to Colorado’s Unclaimed Property
and you have five years of service credit; otherwise
Fund. We encourage you to contact PERA annually
no match will be included.
by phone, email, letter, or go to the PERA website
at www.copera.org and click on the “Claim Your

» If you have five years of service credit under the DPS
Defined Benefit (DB) Plan Account(s)” link under the
benefit structure and choose to receive a monthly
“Members” menu.
benefit in the future, you have the option to enroll
in the PERACare Health Benefits Program and may

» You will need to roll over, refund, or begin receiving a
receive a subsidy toward your health care premium.
monthly benefit by April 1 following the year in which
you reach age 70½ or the IRS will impose a tax

» If you become an inactive member (either because
penalty on your rollover, refund, or benefit. Note: If
your DPS benefit structure DB Plan account is
you roll over your account, you will still be required
frozen through exercising portability, or because
to take a Required Minimum Distribution each year in
you terminated your employment with all PERA
accordance with federal law.
employers) and you are eligible to receive a reduced
or full service retirement benefit, you may apply for a
IF YOU LEAVE YOUR PERA BENEFIT STRUCTURE DB
monthly retirement benefit at the time you become
PLAN ACCOUNT AT PERA
an inactive member or any time in the future. If

» When you are eligible for retirement (see the
you are not eligible to receive a retirement benefit
Colorado PERA Retirement Eligibility fact sheet on the
when you become an inactive member, you are only
PERA website), you may receive a benefit, roll over,
eligible to receive a monthly benefit when you reach
or refund your DB Plan account. If you do a rollover/
full service retirement eligibility.
refund of your DB Plan account, you will receive, at
time of rollover/refund, a 100 percent match equal
See the Colorado PERA Retirement
to your member contributions and interest. If you
Eligibility fact sheet for more information.
are not eligible for retirement, see the specific match
provisions under “Rolling Over or Refunding Your
PERA DB Plan Account(s)” on page 3.

» If you die before your effective date of PERA
retirement, your qualified survivors may be eligible for
a survivor benefit and in some cases, a
lump-sum payment.
2

ROLLING OVER OR REFUNDING YOUR
WHEN YOU ROLL OVER OR REFUND YOUR PERA
PERA DB PLAN ACCOUNT(S)
BENEFIT STRUCTURE DB PLAN ACCOUNT
The forms provided in this booklet are for doing a

» If you are eligible for retirement, you will receive, at
rollover/refund of your DB Plan account(s). To do
time of rollover/refund, a 100 percent match equal to
a rollover or withdraw your PERAPlus 401(k) Plan
your member contributions and interest.
account, PERAPlus 457 Plan account, or PERA DC

» If you are not eligible for retirement, you will receive,
Plan account, call 1-800-759-7372 and select the
at time of rollover/refund, a 50 percent match equal
PERAPlus/DC option.
to your contributions and interest if you have five
The money in your DB Plan account(s) will consist of
years of earned service credit. If you do not have five
your tax-deferred (pre-tax) member contributions and
years of earned service credit:
may contain tax-paid (after-tax) money, which would
• You will receive a 50 percent match on member
have been contributed to the PERA benefit structure
contributions and interest received by PERA on or
before July 1, 1984, and before January 1, 1986, to the
before December 31, 2010.
DPS benefit structure. Your DB Plan account(s) will also
• You will not receive a match on contributions and
contain interest that is compounded annually and any
interest received on or after January 1, 2011.
amounts you paid to purchase service credit. Money
used to purchase service credit may be tax-deferred or
See the Colorado PERA Retirement
tax-paid. PERA’s Customer Service Center can provide
Eligibility fact sheet for more information.
you with the tax-deferred and tax-paid amounts in your
DB Plan account(s).
By law, you are not allowed to do a rollover/refund
WHEN YOU ROLL OVER OR REFUND YOUR DPS
of only a portion of your DB Plan account(s). If
BENEFIT STRUCTURE DB PLAN ACCOUNT
you have a DB Plan account under both the PERA

» You will receive, at time of rollover/refund, a
benefit structure and the DPS benefit structure and
100 percent match equal to your member
you choose to do a rollover/refund, you must do
contributions and interest if you are eligible for
a rollover/refund of both DB Plan accounts unless
retirement, terminated employment on or after
you are eligible to retire from one or both benefit
January 1, 2001, and you have five years of service
structures and choose to take a benefit.
credit; otherwise no match will be included.
To do a rollover/refund of your DB Plan account(s),
PERA’s Customer Service Center can provide you
your employment cannot continue with a PERA
with an estimate of your rollover/refund amount
employer. PERA must verify that your employment
or you may use your User ID and password to
does not continue through any PERA employer and
access the “Termination Options” calculator on
that it has received all of your contributions from your
PERA’s website.
former employer(s). If PERA receives information of
a new membership before your DB Plan account(s)
ROLLING OVER YOUR PERA DB PLAN ACCOUNT(S)
is rolled over/refunded, your Rollover or Refund
Rolling Over the Tax-Deferred Portion:
Request—Defined Benefit Plan will be canceled. Once
your rollover/refund is issued, it cannot be changed or

» You can do a rollover to another account in your
returned to PERA.
name. It cannot be rolled over to an account set up
for anyone else, including your spouse.
Your PERA DB Plan account(s) may be rolled over,
refunded to you, or a combination of these two. You

» The tax-deferred portion of your DB Plan account(s)
may want to consider doing a rollover to another tax-
will remain tax-deferred if you do a rollover to a
deferred plan to avoid immediate taxation of the funds
traditional IRA or eligible employer plan that accepts
and continue to dedicate this money for your retirement.
tax-deferred money.
3


» You may do a direct rollover, which is a payment
» If you decide to have the tax-paid portion paid to
made directly from PERA to an IRA or eligible
you, there will be no tax withholding or penalties,
employer plan, or you may do a rollover within
since federal income taxes have already been paid on
60 days of receiving your PERA refund check if the
these amounts.
tax-deferred portion of your DB Plan account(s) was
REFUNDING YOUR PERA DB PLAN ACCOUNT(S)
paid to you first. (The differences between a direct
» The taxable amount of your DB Plan account(s) will
rollover and a 60-day rollover are explained on
be taxed in the current year unless you roll it over
page 6, “How Do I Do a Rollover?”)
to a traditional IRA or eligible employer plan. Under

» You may be able to do a rollover of your DB Plan
limited circumstances, you may be able to use
account(s) to a traditional IRA, Roth IRA, 401(a),
special tax rules that could reduce the tax you owe
401(k), your PERAPlus 401(k) Plan, 403(a) annuity
(see pages 5–9 or contact a tax professional for
plan, 403(b) tax-sheltered annuity, a 457(b)
more information).
governmental plan, your PERAPlus 457 Plan,

» Your refund may be subject to an IRS 10 percent
or an eligible employer plan that accepts
additional income tax for early distribution if you are
tax-deferred money.
under age 59½. (See page 7, “If I Don’t Do a Rollover,

» You cannot roll to a SIMPLE IRA or Coverdell
Will I Have to Pay the 10 Percent Additional Income Tax
Education Savings Account (formerly known as an
on Early Distributions?”)
Education IRA).

» If your refund is $200 or more, PERA is required to

» If you choose to do a rollover of the tax-deferred
withhold 20 percent of the tax-deferred portion of
portion into a Roth IRA, the amount of the rollover
your DB Plan account(s) and send it to the IRS as
will be included in your taxable income in the year
income tax withholding to be credited against
your rollover is made.
your taxes.

» If you want a portion of the tax-deferred amount in

» PERA does not withhold state tax, but you may be
your DB Plan account(s) paid to you, that portion
responsible for paying state taxes on the full amount
will be paid to you minus 20 percent for federal
when you file your state tax return for the year you
withholding if that portion is $200 or more.
receive the refund.
Rolling Over the Tax-Paid Portion:

» The tax-paid portion (if any) will have no tax
If you have tax-paid money in your DB Plan account(s)
withholding or penalties, since federal income taxes
and want to roll over this portion, obtain the Financial
have already been paid on these amounts.
Institution Certification form from the PERA website.

» After you refund, you can still roll over part of your

» You can do a rollover to another account in your
DB Plan account(s). This is called a 60-day rollover
name. It cannot be rolled over to an account set up
and is explained on page 6, “How Do I Do a Rollover?”
for anyone else, including your spouse.
• The tax-deferred portion can be rolled into an IRA

» The tax-paid portion of your DB Plan account(s) can be
or an eligible employer plan that will accept tax-
paid as a direct rollover to an IRA or an eligible employer
deferred money. Since PERA is required to withhold
plan that accepts tax-paid money.
20 percent for federal income taxes, you may need
to make up this amount from other sources.

» You may be able to do a rollover of your tax-paid
• The tax-paid portion can be rolled into an IRA or to
portion to a 401(a), 401(k), your PERAPlus 401(k) Plan,
an eligible employer plan that will accept tax-paid
or a 403(b) tax-sheltered annuity that accepts tax-
money. You can only roll over tax-paid money to a
paid money. Note: The PERAPlus 457 Plan does not
qualified plan or a 403(b) tax-sheltered annuity via
accept rollovers of tax-paid money.
a direct rollover; it cannot be paid to you first.

» You must have the tax-paid portion directly rolled
over to a qualified plan or 403(b) tax-sheltered
annuity; it may not be paid to you first and then rolled
over to another account.

» An IRA will accept a rollover of the tax-paid portion if
your DB Plan account(s) was paid to you first.
4

IF YOU RETURN TO PERA MEMBERSHIP AFTER A
ROLLOVER/REFUND
PART II: IRS NOTICE

» You may be eligible to purchase all or part of your
forfeited service credit after you have earned one
FOR QUALIFIED
year of service credit with a PERA employer.

» There are different rules for purchasing service credit
DISTRIBUTIONS FROM
from a rolled over/refunded account under the PERA
and DPS benefit structures.
YOUR PERA 401(A) DB
See the Purchasing Service Credit
PLAN ACCOUNT(S)
brochure for more information.
When you terminate PERA-covered employment, you
have the following options:

» If you purchase service credit based on your rollover/
refund, it will not be considered earned service credit

» Leave your DB Plan account(s) at PERA.
and therefore cannot be used to become eligible for

» Roll over your DB Plan account(s) to an IRA or an
survivor benefits and PERA’s disability program.
eligible employer plan.

» The salary associated with your rollover/refund is not

» Refund your DB Plan account(s) and pay the IRS
used in the calculation of your Highest Average Salary.
10 percent additional income tax for early distribution

» If you return to PERA-covered employment and
if you refund before age 59½.
purchase all or a part of your forfeited service
This section contains a notice from the IRS which
credit, you will be subject to the defined benefit
provides a more detailed and technical explanation of
membership provisions in effect at the time you
doing a rollover/refund of your DB Plan account(s). The
return to PERA membership.
notice has important information you need to review
before you decide to receive a rollover or refund.
SOCIAL SECURITY AND YOUR PERA DB PLAN
ACCOUNT(S)
All or part of your DB Plan account(s) may be eligible
According to the Social Security Administration, any
for rollover by you or PERA as a rollover to an IRA or an
rollover/refund that includes a matching amount
eligible employer plan.
subjects the member’s Social Security benefits to
A rollover is a payment by you (60-day rollover) or PERA
reductions under the Windfall Elimination Provision
(direct rollover) of all or part of the tax-deferred dollars
(WEP) and the Government Pension Offset (GPO). If
of your DB Plan account(s) to another plan or traditional
you do not receive a match with your rollover/refund,
IRA that allows you to continue holding the money tax-
you will not be subject to the WEP or GPO reductions.
deferred until it is paid to you. Your DB Plan account(s)
For more information, see the Social Security website at
cannot be rolled over to a SIMPLE IRA or a Coverdell
www.ssa.gov or call Social Security at 1-800-772-1213.
Education Savings Account. Note: Your payment
HOW TO DO A ROLLOVER/REFUND OF YOUR DB
also can be rolled over to a section 408(a) Roth IRA
PLAN ACCOUNT(S)
subject to the same limits that apply to rollovers from
If you would like to do a rollover/refund of your DB
a traditional IRA to a Roth IRA. PERA cannot determine
Plan account(s), you need to complete only one of the
your eligibility to do a Roth IRA rollover.
forms listed below:
An “eligible employer plan” includes: a plan qualified

» Complete the PERA Rollover Request—Defined
under section 401(a) of the Internal Revenue Code,
Benefit Plan form on pages 13–15 if you want all or
including a 401(k) plan, profit-sharing plan, defined
a portion of your DB Plan account(s) rolled over to
benefit plan, stock bonus plan, and money purchase
another qualifying plan.
plan; a 403(a) annuity plan; a 403(b) tax-sheltered
annuity; and a 457(b) governmental plan.

» Complete the PERA Refund Request—Defined Benefit
Plan form on pages 19–21 if you want all of your DB
Plan account(s) refunded to you.
5

An eligible employer plan is not legally required to
GENERAL INFORMATION ABOUT ROLLOVERS
accept a rollover. Before you decide to do a rollover of
How Can a Rollover Affect My Taxes?
your DB Plan account(s) to another employer plan, you
You will be taxed on a refund of your DB Plan
should find out whether the plan accepts rollovers and,
account(s). You will not be taxed on your DB Plan
if so, the types of distributions it accepts as a rollover.
account(s) if you roll it over. If you are under age 59½
You should also find out about any documents that are
and do not do a rollover, you will also have to pay a
required to be completed before the receiving plan will
10 percent additional income tax on early distributions
accept a rollover.
(unless an exception applies). However, if you do a
Even if a plan accepts rollovers, it might not accept
rollover, you will not have to pay tax until you receive
rollovers of certain types of distributions, such as
payments later and the 10 percent additional income
tax-paid (after-tax) amounts. Because of this, PERA
tax will not apply if those payments are made after you
issues tax-paid amounts as a separate check from your
are age 59½ (or if an exception applies).
tax-deferred amounts. If this is the case, and your DB
Where May I Roll Over the Payment?
Plan account(s) includes tax-paid amounts, you may
You may roll over the payment to either an IRA (an
wish instead to do a rollover of your DB Plan account(s)
individual retirement account or individual retirement
to an IRA or split your rollover amount between the
annuity) or an employer plan (a tax-qualified plan,
employer plan in which you will participate and an IRA.
section 403(b) plan, or governmental section 457(b)
If an employer plan accepts your rollover, the plan
plan) that will accept the rollover. The rules of the IRA or
may restrict subsequent distributions of the rollover
employer plan that holds the rollover will determine your
amount or may require your spouse’s consent for any
investment options, fees, and rights to payment from the
subsequent distribution. A subsequent distribution from
IRA or employer plan (for example, no spousal consent
the plan that accepts your rollover may also be subject
rules apply to IRAs and IRAs may not provide loans).
to different tax treatment than distributions from PERA.
Further, the amount rolled over will become subject to
Check with the administrator of the plan that is to
the tax rules that apply to the IRA or employer plan.
receive your rollover prior to making the rollover.
How Do I Do a Rollover?
If you have additional questions after reading this
There are two ways to do a rollover. You can do either
notice, contact PERA’s Customer Service Center at
a direct rollover or a 60-day rollover.
1-800-759-7372. You may also want to contact a tax
If you do a direct rollover, PERA will make the check
professional before doing a rollover/refund of your DB
payable to your IRA or an employer plan. You should
Plan account(s).
contact the IRA sponsor or the administrator of the
NOTICE SUMMARY
employer plan for information on how to do a
Rules that apply to a rollover of your DB Plan account(s)
direct rollover.
are described in the “General Information About
If you do not do a direct rollover, you may still do a
Rollovers” section. Special rules that only apply in certain
rollover by making a deposit into an IRA or eligible
circumstances are described in the “Special Rules and
employer plan that will accept it. You will have
Options” section.
60 days after you receive the payment payable to you
from PERA to make the deposit. If you do not do a
direct rollover, PERA is required to withhold 20 percent
of the payment for federal income taxes. 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. If you do not roll over the entire
amount of the payment, the portion not rolled over will
be taxed and will be subject to the 10 percent additional
income tax on early distributions if you are under age
59½ (unless an exception applies).
6

How Much May I Roll Over?

» Payments up to the amount of your deductible
If you decide to do a rollover, you may roll over all or
medical expenses.
part of the amount eligible for rollover. Any payment

» Certain payments made while you are on active duty if
from the Plan is eligible for rollover, except:
you were a member of a reserve component called to
A. Required Minimum Distributions after age 70½.
duty after September 11, 2001, for more than 179 days.
Beginning when you reach age 70½ or terminate
If I Do a Rollover to an IRA, Will the 10 Percent
PERA-covered employment, whichever is later, a
Additional Income Tax Apply to Early Distributions
certain portion of your payment cannot be rolled
From the IRA?
over because it is a “Required Minimum Distribution”
If you receive a payment from an IRA when you are
that must be paid to you.
under age 59½, you will have to pay the 10 percent
B. Corrective distributions of contributions that exceed
additional income tax on early distributions from the IRA,
tax law limitations. A distribution that is made because
unless an exception applies. In general, the exceptions
legal limits on certain contributions were exceeded
to the 10 percent additional income tax for early
cannot be rolled over.
distributions from an IRA are the same as the exceptions
for early distributions from a plan (see list to left).
PERA can tell you what portion of a payment is eligible
However, there are a few differences for payments from
for rollover.
an IRA, including:
If I Don’t Do a Rollover, Will I Have to Pay the

» There is no exception for payments after separation
10 Percent Additional Income Tax on Early
from service that are made after age 55.
Distributions?

» The exception for domestic relations orders (DROs)
If you are under age 59½, you will have to pay the
does not apply. However, a special rule applies under
10 percent additional income tax on early distributions
which, as part of a divorce or separation agreement, a
from your DB Plan account (including amounts
tax-free transfer may be made directly to an IRA of a
withheld for income tax) that you do not roll over,
spouse or former spouse.
unless one of the exceptions listed below applies.
This tax is in addition to the regular income tax on the

» The exception for payments made at least annually in
payment not rolled over. The amount that PERA will
equal or close to equal amounts over a specified
automatically withhold for income tax purposes is not
period applies without regard to whether you have
intended to cover the 10 percent additional income tax.
had a separation from service.
You can request that an additional amount be withheld

» There are additional exceptions for (1) payments for
from your payment or you can work with the IRS or
qualified higher education expenses, (2) payments
your tax adviser for payment of this additional tax.
up to $10,000 used in a qualified first-time home
purchase, and (3) payments for health insurance
The 10 percent additional income tax does not apply to
premiums after you have received unemployment
the following payments from the plan:
compensation for 12 consecutive weeks (or would

» Payments made after you terminate PERA-covered
have been eligible to receive unemployment
employment if you will be at least age 55 in the year
compensation but for self-employed status).
you terminate employment.
Will I Owe State Income Taxes?

» Payments made after you terminate PERA-covered
This notice does not describe any state or local income
employment if you are a State Trooper and you are at
tax rules (including withholding rules).
least age 50 in the year you terminate employment.

» Payments that are paid because you retire due
to disability.

» Corrective distributions of contributions that exceed
tax law limitations.

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

» Payments made to an alternate payee under a
domestic relations order (DRO).
7

SPECIAL RULES AND OPTIONS
If You Were Born on or Before January 1, 1936
If Your Payment Includes After-Tax Contributions
If you were born on or before January 1, 1936, and
If your DB Plan account(s) has any after-tax money in
receive a refund of your PERA DB Plan account that
it, that amount will not be taxed if you refund your DB
you do not roll over, special rules for calculating the
Plan account(s).
amount of the tax on the payment might apply to you.
For more information, see IRS Publication 575, Pension
Rollover into an IRA. You may roll over your DB Plan
and Annuity Income.
account(s) that includes after-tax money to an IRA
through either a direct rollover or a 60-day rollover.
If You Roll Over Your Payment to a Roth IRA
You must keep track of the aggregate amount of the
If you roll over the payment to a Roth IRA, a special
after-tax contributions in all of your IRAs (in order to
rule applies under which the amount of the payment
determine your taxable income for later payments from
rolled over (reduced by any after-tax amounts) will be
the IRAs). If you do a direct rollover of only a portion
taxed. However, the 10 percent additional income tax
of your DB Plan account(s) and a portion is paid to
on early distributions will not apply (unless you take the
you, each of the payments will include an allocable
amount rolled over out of the Roth IRA within five years,
portion of the after-tax contributions. If you do a
counting from January 1 of the year of the rollover).
60-day rollover to an IRA of only a portion of your DB
If you roll over the payment to a Roth IRA, later
Plan account(s), the after-tax contributions are treated
payments from the Roth IRA that are qualified
as rolled over last. For example, assume your DB Plan
distributions will not be taxed (including earnings after
account(s) totals $12,000, of which $2,000 is after-
the rollover). A qualified distribution from a Roth IRA is
tax contributions. In this case, if you roll over $10,000
a payment made after you are age 59½ (or after your
to an IRA in a 60-day rollover, no amount is taxable
death or disability, or as a qualified first-time home
because the $2,000 amount not rolled over is treated
buyer distribution of up to $10,000) and after you have
as being after-tax contributions.
had a Roth IRA for at least five years. In applying this
Rollover into an Employer Plan. You may roll over your
five-year rule, you count from January 1 of the year
DB Plan account(s) that includes after-tax money to
for which your first contribution was made to a Roth
an employer plan, but only through a direct rollover
IRA. Payments from the Roth IRA that are not qualified
(and only if the receiving plan separately accounts
distributions will be taxed to the extent of earnings after
for after-tax contributions and is not a governmental
the rollover, including the 10 percent additional income
section 457(b) plan). You can do a 60-day rollover to
tax on early distributions (unless an exception applies).
an employer plan of part of your DB Plan account(s)
You do not have to take Required Minimum Distributions
that includes after-tax contributions, but only up to the
from a Roth IRA during your lifetime. For more
amount of the payment that would be taxable if not
information, see IRS Publication 590-A, Contributions
rolled over.
to Individual Retirement Arrangements (IRAs), and
IRS Publication 590-B, Distributions from Individual
If you have after-tax (tax-paid) money in your account(s)
Retirement Arrangements (IRAs).
and want to roll over this portion, obtain the Financial
Institution Certification form from PERA’s website.
If You Miss The 60-Day Rollover Deadline
Generally, the 60-day rollover deadline cannot be
extended. However, the IRS has 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. 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
user fee.
For more information, see IRS Publication 590-A,
Contributions to Individual Retirement
Arrangements (IRAs).
8

If You Are a Nonresident Alien
For More Information
If you are a nonresident alien and you do not do a
This notice summarizes only the federal (not state or
direct rollover to a U.S. IRA or U.S. employer plan,
local) tax rules that may apply to your rollover/refund.
instead of withholding 20 percent, PERA is generally
The rules described here are complex and contain
required to withhold 30 percent of the payment. If the
many conditions and exceptions that are not included
amount withheld exceeds the amount of tax you owe
in this notice. Therefore, you may want to consult
(as may happen if you do a 60-day rollover), you may
with a tax professional before you do a rollover/refund
request an income tax refund by filing Form 1040NR
of your DB Plan account(s). Also, you can find more
and attaching your Form 1042-S.
detailed information on the federal tax treatment
of payments from an IRA or employer plan in the
If your address is outside of the United States, you
following publications:
must complete one of the following forms for federal
income tax withholding:

» IRS Publication 575, Pension and Annuity Income.

» You must provide to PERA an IRS Form W-9, Request

» IRS Publication 590-A, Contributions to Individual
for Taxpayer Identification Number and Certification,
Retirement Arrangements (IRAs).
if you are a U.S. citizen (even though you reside

» IRS Publication 590-B, Distributions from Individual
outside of the United States). The only purpose of
Retirement Arrangements (IRAs).
this form is to gain your certification that you are a

» IRS Publication 571, Tax-Sheltered Annuity Plans
U.S. citizen; PERA is not requesting you obtain a new
(403(b) Plans).
Taxpayer Identification Number.
These publications are available from a local IRS office,

» You must provide to PERA an IRS Form W-8BEN,
online at www.irs.gov, or by calling 1-800-TAX-FORM.
Certificate of Foreign Status of Beneficial Owner for
United States Tax Withholding, if you are a foreign
person (a nonresident alien) to:
• Establish that you are a foreign person;
• Claim that you are the beneficial owner of the
income for which form W-8BEN is being
provided; and
• Claim a reduced rate of, or exemption from,
withholding as a resident of a foreign country with
which the United States has an income tax treaty
(if applicable).
Additional information is available from the IRS
(1-800-829-1040 or www.irs.gov) in Publication 519,
U.S. Tax Guide for Aliens, and IRS Publication 515,
Withholding of Tax on Nonresident Aliens and
Foreign Entities.
PERA is required by law to withhold 30 percent from
any payments you are to receive if Form W-9 or Form
W-8BEN is not received. If you have any questions about
your tax status, please contact your tax professional.
Other Special Rules
If your refund is less than $200, PERA 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 Publication 3, Armed Forces’ Tax Guide.
9

If you leave your DB Plan account(s) at PERA and choose to take a retirement benefit when eligible, you
will receive a pension benefit check every month until you die.
TAKE A SECOND LOOK
Leaving your money at PERA has its advantages
WHAT YOU GAIN
WHAT YOU LOSE
BY LEAVING YOUR ACCOUNT AT PERA
BY WITHDRAWING YOUR PERA ACCOUNT

» You can receive a pension benefit check every

» You forfeit your right to any future benefit and
month in your retirement for your lifetime (and
will lose an opportunity to have lifetime
payments extend to your survivor after your death,
retirement income.
if you elect a benefit option that permits them).

» You will pay taxes on the money unless it is rolled

» Your PERA account will continue to grow through
over to another tax-deferred plan.
annually compounded interest.

» You may pay a 10 percent IRS penalty.

» Your survivors may receive a monthly benefit or a

» You will lose access to the PERACare Health
lump sum of money.
Benefits Program and the life insurance program

» You will have access to the PERACare Health
through Unum.
Benefits Program in retirement. You may also

» You will lose the right to apply for PERA’s disability
receive a subsidy toward your premium.
program if you have more than five years of service

» You will preserve income earmarked for your
credit and are terminating PERA-covered employment
retirement since you likely didn’t pay into Social
because of a potentially disabling condition.
Security while you were a PERA member.
10

ROLLOVER REQUEST—DEFINED BENEFIT PLAN FORM
11

INFORMATION ABOUT THE ROLLOVER REQUEST—
DEFINED BENEFIT PLAN FORM
To do a rollover of your PERAPlus 401(k)/457 Plan accounts or PERA DC Plan account, call
1-800-759-7372 and select the PERAPlus/DC option.
COMPLETING THE ROLLOVER REQUEST—DEFINED BENEFIT PLAN FORM

» Use the Rollover Request—Defined Benefit Plan form to do a rollover of all or a portion of your
PERA benefit structure and/or DPS benefit structure DB Plan account(s).

» If you would like to refund all of your DB Plan account(s) to yourself, complete the Refund
Request—Defined Benefit Plan form on pages 19–21.

» You must submit a Rollover Request—Defined Benefit Plan form to PERA with an original
signature and notarization; a photocopy or faxed form will not be accepted. Side 2 of this
form may be photocopied if you have more than one employer to certify termination of
employment or if you have more than one financial institution that requires certification.

» Your signature must be notarized in the Notary Public section on page 13.

» If you are refunding any portion of your DB Plan account(s) and would like to have PERA
withhold an additional federal tax amount (20 percent of the refunded amount is automatically
withheld), call the PERA Customer Service Center for additional information.

» If your address is outside of the United States, see “If You Are a Nonresident Alien” on page 9 for
information about income taxes that may be withheld from any portion you do not roll over.
PROCESSING TIME FOR THE ROLLOVER REQUEST—DEFINED BENEFIT
PLAN FORM

» Generally, your check(s) will be issued within 90 days of receiving a Rollover Request—Defined
Benefit Plan form as long as the form is complete.

» Incomplete forms will require PERA to request additional information from you to process your
rollover/refund; if you do not respond to our requests for additional information, your rollover/
refund will be canceled.

» The issue date of your check(s) depends on (1) the date PERA receives your Request form;
(2) the certified date of termination; (3) the end of the month in which you were last on the
payroll report; and (4) the date PERA receives any required supplementary documentation.

» Your check(s) will be mailed to the address you provide on your Request form. Any portion that
is being rolled over will be sent to the IRA or eligible employer plan.
12

Rollover Request—Defined Benefit Plan
Colorado Public Employees’ Retirement Association
PO Box 5800, Denver, Colorado 80217-5800
1-800-759-PERA (7372) • www.copera.org
Member SSN
See instructions for completing this form to the left on page 12.
Member
Information
Name ________________________________________________________________________________________________
Name must be the

Last
First MI
same as the name
Address ______________________________________________________________________________________________
on your Social

Street
City
State
ZIP Code
Security card
Daytime Telephone _______________________________
( )
Birthdate __________________________
Rollover
I understand that my choices below will affect both my PERA benefit structure and DPS benefit structure Defined Benefit
(DB) Plan accounts (if applicable). I would like the tax-deferred portion distributed to me in the following manner:
Roll over ____________ % or $ ______________ (fixed-dollar amount) of the tax-deferred portion of my DB Plan account(s)
to my IRA or eligible employer plan in the Financial Institution Certification section on the reverse side. If the amount you are
requesting is not 100 percent or the entire account(s) balance, the remainder will be paid to you minus 20 percent for federal tax
withholding.
If you have tax-paid money in your account(s), it will be paid to you without any tax withholding. If you want to roll over this
portion, obtain the Financial Institution Certification form from the PERA website.
Member
I have read all of the information provided in the Refund/Rollover Request booklet and I understand that by rolling over/
Certification
refunding my DB Plan account(s):
• I will forfeit any rights associated with my present DB Plan account(s), my right to any future benefits with PERA, and I am solely
responsible for all taxes and consequences of my decision.
• My rollover and any portion that is refunded to me will be paid to me in the manner I requested, and I understand once it is
paid, my rollover/refund cannot be reissued or returned to PERA.
• With my signature below, I wish to waive the 30-day waiting period the Internal Revenue Code affords me and I understand
that this waiver does not guarantee my rollover/refund will be sent to me in less than 30 days. Note: Call PERA if you do not
wish to waive this waiting period.
• I understand that my DB Plan account(s) will be refunded to me and/or rolled over to my financial institution within 90 days
of PERA receiving the necessary documentation, which includes any information from me, my former employer(s), and my
financial institution to process my rollover/refund.
• I understand that PERA may discuss this rollover with the receiving financial institution(s) named in the Financial Institution
Certification section on the reverse side.
Sign Here è Member Signature ________________________________________________________ Date _________________________
Notary Public
Have a notary public complete the certification below (required).
Places for you to have
State of________________________________ County of _______________________________
this form notarized
include your employer,
Acknowledged before me, this ___________ day of _________________________ 20 ______ ,
bank, or at PERA
by _____________________________________________ .
Witness my official hand and seal. Commission expires: ___________________________
Notary Public ___________________________________________________________
Form continued on reverse
8/372-refundroll (REV 8-16)
13
Submit original form to PERA

Rollover Request—Defined Benefit Plan (Page 2)
Colorado Public Employees’ Retirement Association
PO Box 5800, Denver, Colorado 80217-5800
1-800-759-PERA (7372) • www.copera.org
Name ______________________________________________________ SSN _____________________________
Termination
To be completed and signed by payroll office.
Certification by
Employer: Please return this form, which must be signed by a certifying official, promptly to PERA. If the employee has
Former Payroll
been off your PERA Contribution Report for more than 90 days (unless on a leave of absence), you do not need to complete
Office
this certification.
1. Specify the last date the member was or will be paid through (including contract payments and annual leave accrual paid in
advance) or the last day of unpaid leave of absence, whichever is later
If you received a

__________________________
paycheck from your

month/day/year
PERA employer within
the past 90 days,
2. Specify the final month the member will appear on your Contribution Report
__________________________
have your employer

month/year
complete this section
3. Specify the total member contributions (including adjustments) reported for the
If you were paid by
member on all Contribution Reports submitted for the final month
$ __________________________
more than one PERA

employer, make copies
4. Has this member terminated employment?
q Yes q No
of this page and
If yes, what is the termination date?


__________________________
have each employer

month/day/year
complete this section
_____________________________________________________________________________________________________
Signature and Title of Certifying Official (Payroll Specialist)
Date
_____________________________________________________________________________________________________
( )
Employer Name (please print)
Employer Number
Telephone Number
Financial
Institution
Instructions: You are required to have an authorized representative from the recipient financial institution or plan administrator
Certification
complete and sign the information below. If you are rolling over your DB Plan account(s) to your PERAPlus 401(k) or 457 Plan,
certification is not required. If you have tax-paid money in your account(s) and want to roll it over, obtain the Financial Institution
Certification form from PERA’s website.
è
Member: Choose ONE plan below to have the tax-deferred portion of your DB Plan account(s) rolled into:
Member complete q Traditional IRA
q Roth IRA
q Qualified Plan
this section q 403(a) Annuity Plan
q 403(b) Tax-Sheltered Annuity
q 457(b) Governmental Plan
(check one box only)
q PERAPlus 401(k) Plan*
q PERAPlus 457 Plan*

(You must have an existing PERAPlus 457 Plan account)
* If you choose the PERAPlus 401(k) or PERAPlus 457 Plan, you do not need certification below.
è
IRA custodian or plan representative: Complete and sign the information below.
THIS CERTIFICATION CANNOT BE COMPLETED BY THE PERA MEMBER.
Authorized
representative from
Make check payable to __________________________________________________________________________________
financial institution
complete this section Our institution will accept (check one):
q The entire tax-deferred portion or

q The following amount $ ______________________________
Name of IRA Custodian or Plan _________________________________________ Account Number ____________________
Address ______________________________________________________________________________________________

Street
City
State
ZIP Code
Sign Here è Signature of IRA Custodian or Plan Representative _____________________________________________________________
Authorized Print Name of IRA Custodian or Plan Representative ____________________________________________________________
representative
Title of IRA Custodian or Plan Representative _________________________________________________________________
Telephone Number ______________________________
( )
Form continued on next page
14

Rollover Request—Defined Benefit Plan (Page 3)
Colorado Public Employees’ Retirement Association
PO Box 5800, Denver, Colorado 80217-5800
1-800-759-PERA (7372) • www.copera.org
Name ______________________________________________________ SSN _____________________________
Copy of Social
Attach a Legible Photocopy of Your Signed Social Security Card Below.
Security Card
• DO NOT SEND YOUR ORIGINAL SOCIAL SECURITY CARD.
Attach a photocopy of
• Your Social Security card must have your current name.
your Social Security
• If you do not have a copy of your Social Security card or need a new card, contact Social Security at 1-800-772-1213.
card if you worked
less than 18 months for
a PERA employer
Extend transparent tape to edges of card. Do not staple or glue.
15


REFUND REQUEST—DEFINED BENEFIT PLAN FORM
17

INFORMATION ABOUT THE REFUND REQUEST—
DEFINED BENEFIT PLAN FORM
To withdraw your PERAPlus 401(k)/457 Plan accounts or PERA DC Plan account, call
1-800-759-7372 and select the PERAPlus/DC option.
COMPLETING THE REFUND REQUEST—DEFINED BENEFIT PLAN FORM

» Use this Refund Request—Defined Benefit Plan form to refund your PERA benefit structure and/or
DPS benefit structure DB Plan account(s).

» If you would like to roll over all or a portion of your DB Plan account(s), use the Rollover Request—
Defined Benefit Plan form on pages 13–15.

» You must submit a Refund Request—Defined Benefit Plan form to PERA with an original signature and
notarization; a photocopy or faxed form will not be accepted. Side 2 of this form may be photocopied
if you have more than one employer to certify termination of employment.

» Your signature must be notarized in the Notary Public section on page 19.

» If you would like to have PERA withhold an additional federal tax amount (20 percent is automatically
withheld), call the PERA Customer Service Center for additional information.

» If your address is outside of the United States, see “If You Are a Nonresident Alien” on page 9 for
information about income taxes that may be withheld from your refund.
PROCESSING TIME FOR THE REFUND REQUEST—DEFINED BENEFIT PLAN FORM

» Generally, your check(s) will be issued within 90 days of receiving a Refund Request—Defined Benefit
Plan form as long as the form is complete.

» Incomplete forms will require PERA to request additional information from you to process your
refund; if you do not respond to our requests for additional information, your refund will be canceled.

» The issue date of your check(s) depends on (1) the date PERA receives your Request form;
(2) the certified date of termination; (3) the end of the month in which you were last on the payroll
report; and (4) the date PERA receives any required supplementary documentation.

» Your check(s) will be mailed to the address you provide on your Request form.
18

Refund Request—Defined Benefit Plan
Colorado Public Employees’ Retirement Association
PO Box 5800, Denver, Colorado 80217-5800
1-800-759-PERA (7372) • www.copera.org
Member SSN
See instructions for completing this form to the left on page 18.
Member
Information
Name must be the
Name ________________________________________________________________________________________________
same as the name

Last
First MI
on your Social
Address ______________________________________________________________________________________________
Security card

Street
City
State
ZIP Code
Your refund check(s)
Daytime Telephone _______________________________
( )
Birthdate __________________________
will mail to this address
Refund
By requesting a refund of my Defined Benefit (DB) Plan account(s), I understand that:
• I am refunding my entire DB Plan account(s) to myself, and if I have both a PERA benefit structure and DPS benefit structure
account, it applies to both DB Plan accounts.
• Federal income tax will be deducted at a rate of 20 percent from the tax-deferred portion of my refund.
• There may be a 10 percent additional income tax for early distribution imposed by the IRS for refunding. (See “If I Don’t Do a
Rollover, Will I Have to Pay the 10 Percent Additional Income Tax on Early Distributions?” on page 7.)
Member
Certification
I have read all of the information provided in the Refund/Rollover Request booklet and I understand that by refunding my
DB Plan account(s):
• I will forfeit any rights associated with my present DB Plan account(s), my right to any future benefits with PERA, and I am solely
responsible for all taxes and consequences of my decision.
• My refund will be paid to me in the manner I requested, and I understand once it is paid, my refund cannot be reissued or
returned to PERA.
• With my signature below, I wish to waive the 30-day waiting period the Internal Revenue Code affords me and I understand
that this waiver does not guarantee my refund will be sent to me in less than 30 days. Note: Call PERA if you do not wish to
waive this waiting period.
• I understand that my DB Plan account(s) will be refunded to me within 90 days of PERA receiving the necessary documentation,
which includes any information from me and my former employer(s) to process my refund.
Sign Here è Member Signature ________________________________________________________ Date _________________________
Notary Public
Have a notary public complete the certification below (required).
Places for you to have State of________________________________ County of ______________________________
this form notarized Acknowledged before me, this ___________ day of _________________________ 20 ______ ,
include your employer,
bank, or at PERA
by _____________________________________________ .
Witness my official hand and seal. Commission expires: ___________________________
Notary Public ___________________________________________________________
Form continued on reverse
8/3-refund (REV 8-16)
19
Submit original form to PERA

Refund Request—Defined Benefit Plan (Page 2)
Colorado Public Employees’ Retirement Association
PO Box 5800, Denver, Colorado 80217-5800
1-800-759-PERA (7372) • www.copera.org
Name ______________________________________________________ SSN _____________________________
Termination
To be completed and signed by payroll office.
Certification by
Employer: Please return this form, which must be signed by a certifying official, promptly to PERA. If the employee has
Former Payroll
been off your PERA Contribution Report for more than 90 days (unless on a leave of absence), you do not need to complete
Office
this certification.
1. Specify the last date the member was or will be paid through (including contract payments and annual leave accrual paid in
advance) or the last day of unpaid leave of absence, whichever is later
If you received a
__________________________
paycheck from your
month/day/year
employer within the
past 90 days, have 2. Specify the final month the member will appear on your Contribution Report
__________________________
your employer
month/year
complete this section
3. Specify the total member contributions (including adjustments) reported for the
If you were paid by
member on all Contribution Reports submitted for the final month
$ __________________________
more than one PERA
employer, make copies 4. Has this member terminated employment?
q Yes q No
of this page and
If yes, what is the termination date?


__________________________
have each employer
month/day/year
complete this section _____________________________________________________________________________________________________
Signature and Title of Certifying Official (Payroll Specialist)
Date
_____________________________________________________________________________________________________
( )
Employer Name (please print)
Employer Number
Telephone Number
Form continued on next page
20

Refund Request—Defined Benefit Plan (Page 3)
Colorado Public Employees’ Retirement Association
PO Box 5800, Denver, Colorado 80217-5800
1-800-759-PERA (7372) • www.copera.org
Name ______________________________________________________ SSN _____________________________
Copy of Social
Attach a Legible Photocopy of Your Signed Social Security Card Below.
Security Card
• DO NOT SEND YOUR ORIGINAL SOCIAL SECURITY CARD.
Attach a photocopy of
• Your Social Security card must have your current name.
your Social Security
• If you do not have a copy of your Social Security card or need a new card, contact Social Security at 1-800-772-1213.
card if you worked less
than 18 months for a
PERA employer
Extend transparent tape to edges of card. Do not staple or glue.
21

ACCESSING YOUR PERA ACCOUNT
You can access your personal PERA information by
logging into your account through www.copera.org.

» You need a User ID and password to access your
account. If you have not yet set up your User ID
and password, you will first need a PERA Personal
Identification Number (PIN).
• You can request a PIN by clicking on the “PIN
Request” link from the “Members” or “Retirees”
menus on PERA’s website. Your new PIN will
arrive by mail within seven business days. If you
need to access your account before then, please
call the PERA Customer Service Center.
• PERAPlus 401(k), 457, and PERA DC Plan
participants are mailed PINs shortly after making
the first contribution to the Plan(s). If you have
forgotten or misplaced your PIN, you may
request a new one by following the steps above.

» You will then log in with your Social Security
Contact PERA
number (SSN) and PERA PIN.
• After logging in with your SSN and PIN, you will
be prompted to create a user security profile with
a User ID and password.
Visit PERA’s website at

» Once your user security profile is complete, you will
www.copera.org.
no longer use your SSN and PIN to access your
account. You will use your User ID and password
combination instead.
• You will need to retain your PIN when speaking to
a Voya Financial Participant Services
Call PERA’s Customer Service
Representative to obtain PERAPlus 401(k), 457, and
Center at 1-800-759-7372.
PERA DC Plan information.
If you have any questions about accessing your
account, please call the PERA Customer Service
Center at 1-800-759-7372.
Visit the PERA offices in Denver,
Lone Tree, and Westminster.
This booklet provides information about refunding/rolling
Send mail to PERA at
over your PERA Defined Benefit Plan account. Your rights,
PO Box 5800
benefits, and obligations as a PERA member are governed
Denver, CO 80217-5800
by Title 24, Article 51 of the Colorado Revised Statutes and
the Rules of the Colorado Public Employees’ Retirement
Association, which take precedence over any interpretations
Forms and publications can be found
in this booklet.
on the PERA website. Copies can
8/3 (REV 8-16) 10M
also be requested by calling PERA's
Customer Service Center.
Printed on recycled paper