State Employees Retirement System R E T I R E M E N T C H E C K L I S T

Application Process We recommend you return your pension application within 30-90 days prior to your retirement. Applications received more than 90 days prior to your retirement date will be returned to you.

The following are required to be returned to SERS: Retirement Application (Form 3004)A photocopy of your birth certificate, if not already on file (see Form 3004)Retiree Insurance Form (Form 3991)Depository Agreement for SERS Benefit Payments (Form 3967)Withholding Certificate for Pension or Annuity Payments (Form W-4P)Copy of Medicare card for yourself and dependents, if applicable

The following are encouraged (if applicable) to be returned to SERS:If married, a photocopy of your marriage certificate and your spouse’s birth certificateIf divorced, a photocopy of your divorce decree (first page and Judge’s signature page only)If widowed, a photocopy of your spouse’s death certificate or obituaryRollover/Tax Election - Survivor Contribution Refund, if applicable (Form 3153)Death Benefit Beneficiary Designation (Form 101) (if you need to update your beneficiaries)If you wish to purchase additional service credit, (ex. qualifying/short periods, military service, refunded contributions or leaves of absence) you must do so prior to retirement (Form 2003)If you wish to have optional deductions from your retirement check (ex. American Family, Prudential, credit union, etc.), return a photocopy of the authorization/deduction cards from the institution If you are currently enrolled in the NCPERS Voluntary Life Program ($8.00 per pay) and wish to continue these deductions from your retirement check, you must re-enroll. Contact SERS for a re-enrollment card at 217-785-7444 and you will be directed to the Benefits Support Section .

SERS will send a letter of confirmation once your completed retirement application is received.

Coordinate with Agency/Reciprocal SystemsNotify your agency of your intent to retire and the date you wish to retire and contact your Retirement Coordinator for agency assistance.

If you want to acquire additional service credit on your paid sick and paid vacation days, complete Form #1404 with your agency payroll officer.Resign from your agency by signing the appropriate documents.If you are on disability, you must resign from your leave of absence in order to retire.Layoff, discharge or dismissal is considered a final personnel action for retirement purposes and resignation is not required.If you are retiring under the Reciprocal Act you must make application with all systems.

3974 (R-10-17)

3004 (R 9 - 17) - over -

RETIREMENT APPLICATION(Please Print or Type)

Effective Date of Your Pension - __________ ______ ________ Birth Certificate Required Yes No Complete the following if there is no label or the label is incorrect!

Name

Address City State Zip Code

Phone Number (H) (C)

Date of Birth Email Address

Current Marital Status (check one box) Single, Divorced, Widowed Married - Date of Marriage or Civil Union: Month _____________ Day___________ Year _________

List all minor children, even if not living with you (including natural, adopted or step children) under age 18 or under age 22 if a full-time student and/or over age 18 who are physically or mentally disabled and/or dependent parents.

Name ________________________ Relationship ________________ Date of Birth______________ Disabled Yes No

Name ________________________ Relationship ________________ Date of Birth _____________ Disabled Yes No

Name ________________________ Relationship ________________ Date of Birth _____________ Disabled Yes No

If you are single with no dependents or have been married for less than 1 year, do you want a refund of survivor contributions? Yes No If you receive a refund of your survivor contributions, survivor benefits are not payable at the time of your death.

Were you ever convicted of a felony relating to or arising out of or in connection with your service as a SRS member? Yes No

If currently receiving SERS disability benefits, I understand these benefits will be terminated and pension benefits will begin.

STATE RETIREMENT SYSTEMS

State Employees' Retirement System of Illinois General Assembly Retirement SystemJudges' Retirement System of Illinois

2101 South Veterans Parkway, P.O. Box 19255, Springfield, IL 62794-9255Internet: http://www.srs.illinois.gov E-Mail: sers@srs.illinois.gov

Month Day Year1st Last 4 of SSN

Social Security Offset Removal:

As part of your SERS benefits, your qualified survivor(s) will be eligible for a survivor annuity after your death. If you contributed to Social Security as a state employee, an offset of 50% is usually applied to the survivor benefit when the survivor becomes eligible for Social Security benefits. You may elect to reduce your retirement annuity by 3.825% to avoid the offset that may be applied to a future survivor annuity.

Please check one: I elect to participate and authorize SERS to reduce my monthly benefit by 3.825%.

I do not elect to participate

Level Income Option:

Only members who contribute to Social Security (SSA) are eligible for the Level Income Option. This option increases your pension immediately by a percentage of what you are eligible to receive from SSA. Your pension will later be reduced by the full amount you are eligible to receive at the age chosen below. You must submit a Social Security Estimate dated within 6 months of your retirement date which will be used to calculate the Level Income Option.

A retiring member with a QILDRO on file with SERS may not choose the level income option without first contacting the QILDRO Department at (217) 524-6965. A pension that includes a QILDRO and level income requires additional processing time.

I fully understand the level income option and that my pension will be reduced at the age of my election.

Please check one: I elect the Level Income Option for age 62 years and 1 month.

I elect the Level Income Option for the age at which I will receive unreduced social security benefits. I do not elect the Level Income Option, or it does not apply to me.

Special note for those electing the Level Income Option: SERS benefits are paid for the current month (July’s payment is paid in July) and Social Security Benefits are paid one month behind (July’s payment is paid in August); therefore, there will be one month that you will receive reduced benefits from SERS and receive no Social Security Benefits.

Reciprocal Service:

Do you have service credits in any of the following systems? Yes No If yes, check only the systems you wish to have computed under the Retirement Systems Reciprocal Act (you must make application with all systems).

County Employees’ Annuity & Benefit Fund of Cook County Metropolitan Water Reclamation District Retirement Fund Forest Preserve District Employees’ Annuity & Benefit Fund of Cook County Park Employees’ Annuity & Benefit Fund Illinois Municipal Retirement Fund Chicago Teachers’ Pension Fund General Assembly Retirement System Judges’ Retirement System of Illinois Laborers’ Annuity & Benefit Fund State Teachers’ Retirement System Municipal Employees’ Annuity & Benefit Fund of Chicago State Universities’ Retirement System

I certify this information is correct. I am aware that pursuant to the 40 ILCS 5/1-135 any person who knowingly makes a false state-ment or falsifies a record in an attempt to defraud the State Employees’ Retirement System is guilty of a class 3 felony. If the SERS Board of Trustees has a reasonable suspicion that an attempt has been made to defraud SERS, it is required to report the matter to the appropriate state’s attorney for investigation.

Signature _________________________________________________ Date _____________________________________

RETURN COMPLETED APPLICATION TO: State Employees’ Retirement System or FAX TO: 217-524-2293 2101 S. Veterans Parkway P.O. Box 19255 Email Not Accepted Springfield Illinois 62794-9255

Form W-4PDepartment of the Treasury Internal Revenue Service

Withholding Certificate for Pension or Annuity Payments

OMB No. 1545-0074

2018Future developments. For the latest information about any future developments related to Form W 4P, such as legislation enacted after it was published, go to www.irs.gov/FormW4P.Purpose. Form W 4P is for U.S. citizens, resident aliens, or their estates who are recipients of pensions, annuities (including commercial annuities), and certain other deferred compensation. Use Form W 4P to tell payers the correct amount of federal income tax to withhold from your payment(s). You also may use Form W 4P to choose (a) not to have any federal income tax withheld from the payment (except for eligible rollover distributions or for payments to U.S. citizens to be delivered outside the United States or its possessions) or (b) to have an additional amount of tax withheld.

Your options depend on whether the payment is periodic, nonperiodic, or an eligible rollover distribution, as explained on pages 2 and 3. Your previously filed Form W 4P will remain in effect if you don’t file a Form W 4P for 2018.

General InstructionsSection references are to the Internal Revenue Code.

Follow these instructions to determine the number of withholding allowances you should claim for pension or annuity payment withholding for 2018 and any additional amount of tax to have withheld. Complete the worksheet(s) using the taxable amount of the payments.

If you don’t want any federal income tax withheld (see Purpose, earlier), you can skip the worksheets and go directly to the Form W 4P below.Sign this form. Form W 4P is not valid unless you sign it.

You can also use the calculator at www.irs.gov/W4App to determine your tax withholding more accurately. Consider using this calculator if you have a more complicated tax situation, such as if you have more than one pension or annuity, a working spouse, or a large amount of income outside of your pensions. After your Form W 4P takes effect, you can also use this calculator to see how the amount of tax you’re having withheld compares to your projected total tax for 2018. If you use the calculator, you don’t need to complete any of the worksheets for Form W 4P.

Note that if you have too much tax withheld, you will receive a refund when you file your tax return. If you have too little tax

withheld, you will owe tax when you file your tax return, and you might owe a penalty.Filers with multiple pensions or more than one income. If you have more than one source of income subject to withholding (such as more than one pension or a pension and a job, or you’re married and your spouse is working), read all of the instructions, including the instructions for the Multiple Pensions/More Than One Income Worksheet, before beginning.Other income. If you have a large amount of income from other sources not subject to withholding (such as interest, dividends, or capital gains), consider making estimated tax payments using Form 1040 ES, Estimated Tax for Individuals. Otherwise, you might owe additional tax. See Pub. 505, Tax Withholding and Estimated Tax, for more information. Get Form 1040 ES and Pub. 505 at www.irs.gov/FormsPubs. Or, you can use the Deductions, Adjustments, and Additional Income Worksheet on page 5 or the calculator at www.irs.gov/W4App to make sure you have enough tax withheld from your payments. If you have income from wages, see Pub. 505 or use the calculator at www.irs.gov/W4App to find out if you should adjust your withholding on Form W 4 or Form W 4P.Note: Social security and railroad retirement payments may be includible in income. See Form W 4V, Voluntary Withholding Request, for information on voluntary withholding from these payments.

Withholding From Pensions and AnnuitiesGenerally, federal income tax withholding applies to the taxable part of payments made from pension, profit-sharing, stock bonus, annuity, and certain deferred compensation plans; from individual retirement arrangements (IRAs); and from commercial annuities. The method and rate of withholding depend on (a) the kind of payment you receive; (b) whether the payments are to be delivered outside the United States or its possessions; and (c) whether the recipient is a nonresident alien individual, a nonresident alien beneficiary, or a foreign estate. Qualified distributions from a Roth IRA are nontaxable and, therefore, not subject to withholding. See page 3 for special withholding rules that apply to payments to be delivered outside the United States and payments to foreign persons.

Separate here and give Form W-4P to the payer of your pension or annuity. Keep the worksheet(s) for your records.

Form W-4PDepartment of the Treasury Internal Revenue Service

Withholding Certificate for Pension or Annuity Payments

For Privacy Act and Paperwork Reduction Act Notice, see page 6.

OMB No. 1545-0074

2018Your first name and middle initial Last name Your social security number

Home address (number and street or rural route)

City or town, state, and ZIP code

Claim or identification number (if any) of your pension or annuity contract

Complete the following applicable lines.

1 Check here if you do not want any federal income tax withheld from your pension or annuity. (Don’t complete line 2 or 3.) 2

Total number of allowances and marital status you’re claiming for withholding from each periodic pension or annuity payment. (You also may designate an additional dollar amount on line 3.) . . . . . . . . . . .

(Enter number of allowances.)

Marital status: Single Married Married, but withhold at higher Single rate.3

Additional amount, if any, you want withheld from each pension or annuity payment. (Note: For periodic payments, you can’t enter an amount here without entering the number (including zero) of allowances on line 2.) . . . . $

Your signature Date

Cat. No. 10225T Form W-4P (2018)

Form W-4P (2018) Page 2

Because your tax situation may change from year to year, you may want to refigure your withholding each year. You can change the amount to be withheld by using lines 2 and 3 of Form W-4P.Choosing not to have income tax withheld. You (or in the event of death, your beneficiary or estate) can choose not to have federal income tax withheld from your payments by using line 1 of Form W-4P. For an estate, the election to have no income tax withheld may be made by the executor or personal representative of the decedent. Enter the estate’s employer identification number (EIN) in the area reserved for “Your social security number” on Form W-4P.

You may not make this choice for eligible rollover distributions. See Eligible rollover distribution—20% withholding below.Caution: There are penalties for not paying enough federal income tax during the year, either through withholding or estimated tax payments. New retirees, especially, should see Pub. 505. It explains your estimated tax requirements and describes penalties in detail. You may be able to avoid quarterly estimated tax payments by having enough tax withheld from your pension or annuity using Form W-4P. Periodic payments. Withholding from periodic payments of a pension or annuity is figured in the same manner as withholding from wages. Periodic payments are made in installments at regular intervals over a period of more than 1 year. They may be paid annually, quarterly, monthly, etc.

If you want federal income tax to be withheld, you must designate the number of withholding allowances on line 2 of Form W-4P and indicate your marital status by checking the appropriate box. You can’t designate a specific dollar amount to be withheld. However, you can designate an additional amount to be withheld on line 3.

If you don’t want any federal income tax withheld from your periodic payments, check the box on line 1 of Form W-4P and submit the form to your payer. However, see Payments to Foreign Persons and Payments To Be Delivered Outside the United States on page 3.Caution: If you don’t submit Form W-4P to your payer, the payer must withhold on periodic payments as if you’re married claiming three withholding allowances. Generally, this means that tax will be withheld if the taxable amount of your pension or annuity is at least $1,990 a month.

If you submit a Form W-4P that doesn’t contain your correct social security number (SSN), the payer must withhold as if

you’re single claiming zero withholding allowances even if you checked the box on line 1 to have no federal income tax withheld.

There are some kinds of periodic payments for which you can’t use Form W-4P because they’re already defined as wages subject to federal income tax withholding. These payments include retirement pay for service in the U.S. Armed Forces and payments from certain nonqualified deferred compensation plans and tax-exempt organizations’ deferred compensation plans described in section 457. Your payer should be able to tell you whether Form W-4P applies.

For periodic payments, your Form W-4P stays in effect until you change or revoke it. Your payer must notify you each year of your right to choose not to have federal income tax withheld (if permitted) or to change your choice.Nonperiodic payments—10% withholding. Your payer must withhold at a flat 10% rate from the taxable amount of nonperiodic payments (but see Eligible rollover distribution—20% withholding below) unless you choose not to have federal income tax withheld. Distributions from an IRA that are payable on demand are treated as nonperiodic payments. You can choose not to have federal income tax withheld from a nonperiodic payment (if permitted) by submitting Form W-4P (containing your correct SSN) to your payer and checking the box on line 1. However, see Payments to Foreign Persons and Payments To Be Delivered Outside the United States on page 3. Generally, your choice not to have federal income tax withheld will apply to any later payment from the same plan. You can’t use line 2 for nonperiodic payments. But you may use line 3 to specify an additional amount that you want withheld.Caution: If you submit a Form W-4P that doesn’t contain your correct SSN, the payer can’t honor your request not to have income tax withheld and must withhold 10% of the payment for federal income tax.Eligible rollover distribution—20% withholding. Distributions you receive from qualified pension or annuity plans (for example, 401(k) plans and section 457(b) plans maintained by a governmental employer) or tax-sheltered annuities that are eligible to be rolled over to an IRA or qualified plan are subject to a flat 20% federal withholding rate on the taxable amount of the distribution. The 20% withholding rate is required, and you can’t choose not to have income tax withheld from eligible rollover distributions. Don’t give Form W-4P to your payer unless you want an additional amount withheld. In that case, complete line 3 of Form W-4P and submit the form to your payer.

Form W-4P (2018) Page 3

Note: The payer won’t withhold federal income tax if the entire distribution is transferred by the plan administrator in a direct rollover to a traditional IRA or another eligible retirement plan (if allowed by the plan), such as a 401(k) plan, qualified pension plan, governmental section 457(b) plan, section 403(b) contract, or tax-sheltered annuity.

Distributions that are (a) required by federal law, (b) one of a specified series of equal payments, or (c) qualifying “hardship” distributions are not “eligible rollover distributions” and aren’t subject to the mandatory 20% federal income tax withholding. See Pub. 505 for details. See also Nonperiodic payments—10% withholding on page 2.Tax relief for victims of terrorist attacks. For tax years ending after September 10, 2001, disability payments for injuries incurred as a direct result of a terrorist attack directed against the United States (or its allies), whether outside or within the United States, aren’t included in income. You may check the box on line 1 of Form W-4P and submit the form to your payer to have no federal income tax withheld from these disability payments. However, you must include in your income any amounts that you received or you would’ve received in retirement had you not become disabled as a result of a terrorist attack. See Pub. 3920, Tax Relief for Victims of Terrorist Attacks, for more details.

Changing Your “No Withholding” ChoicePeriodic payments. If you previously chose not to have federal income tax withheld and you now want withholding, complete another Form W-4P and submit it to your payer. If you want federal income tax withheld at the 2018 default rate (married with three allowances), write “Revoked” next to the checkbox on line 1 of the form. If you want tax withheld at any different rate, complete line 2 on the form.Nonperiodic payments. If you previously chose not to have federal income tax withheld and you now want withholding, write “Revoked” next to the checkbox on line 1 and submit Form W-4P to your payer.

Payments to Foreign Persons and Payments To Be Delivered Outside the United StatesUnless you’re a nonresident alien, withholding (in the manner described above) is required on any periodic or nonperiodic payments that are to be delivered to you outside the United States or its possessions. You can’t choose not to have federal income tax withheld on line 1 of Form W-4P. See Pub. 505 for details.

In the absence of a tax treaty exemption, nonresident aliens, nonresident alien beneficiaries, and foreign estates generally are subject to a 30% federal withholding tax under section 1441 on the taxable portion of a periodic or nonperiodic pension or annuity payment that is from U.S. sources. However, most tax treaties provide that private pensions and annuities are exempt from withholding and tax. Also, payments from certain pension plans are exempt from withholding even if no tax treaty applies. See Pub. 515, Withholding of Tax on Nonresident Aliens and Foreign Entities, and Pub. 519, U.S. Tax Guide for Aliens, for details. A foreign person should submit Form W-8BEN, Certificate of Foreign Status of Beneficial Owner for United States Tax Withholding and Reporting, to the payer before receiving any payments. The Form W-8BEN must contain the foreign person’s taxpayer identification number (TIN).

Statement of Federal Income Tax Withheld From Your Pension or AnnuityBy January 31 of next year, your payer will furnish a statement to you on Form 1099-R, Distributions From Retirement Plans, Insurance Contracts, etc., showing the total amount of your pension or annuity payments and the total federal income tax withheld during the year. If you’re a foreign person who has provided your payer with Form W-8BEN, your payer instead will

furnish a statement to you on Form 1042-S, Foreign Person’s U.S. Source Income Subject to Withholding, by March 15 of next year.

Specific Instructions

Personal Allowances WorksheetComplete this worksheet on page 4 first to determine the number of withholding allowances to claim.Line C. Head of household please note: Generally, you can claim head of household filing status on your tax return only if you’re unmarried and pay more than 50% of the costs of keeping up a home for yourself and a qualifying individual. See Pub. 501 for more information about filing status.Line E. Child tax credit. When you file your tax return, you might be eligible to claim a credit for each of your qualifying children. To qualify, the child must be under age 17 as of December 31 and must be your dependent who lives with you for more than half the year. To learn more about this credit, see Pub. 972, Child Tax Credit. To reduce the tax withheld from your payments by taking this credit into account, follow the instructions on line E of the worksheet. On the worksheet you will be asked about your total income. For this purpose, total income includes all of your pensions, wages, and other income, including income earned by a spouse, during the year.Line F. Credit for other dependents. When you file your tax return, you might be eligible to claim a credit for each of your dependents that don’t qualify for the child tax credit, such as any dependent children age 17 and older. To learn more about this credit, see Pub. 505. To reduce the tax withheld from your payments by taking this credit into account, follow the instructions on line F of the worksheet. On the worksheet, you will be asked about your total income. For this purpose, total income includes all of your pensions, wages, and other income, including income earned by a spouse, during the year.Line G. Other credits. You might be able to reduce the tax withheld from your payments if you expect to claim other tax credits, such as the earned income tax credit and tax credits for education and child care expenses. If you do so, your payments will be larger but the amount of any refund that you receive when you file your tax return will be smaller. Follow the instructions for Worksheet 1 6 in Pub. 505 if you want to reduce your withholding to take these credits into account.

Deductions, Adjustments, and Additional Income WorksheetComplete this worksheet to determine if you’re able to reduce the tax withheld from your pension or annuity payments to account for your itemized deductions and other adjustments to income, such as IRA contributions. If you do so, your refund at the end of the year will be smaller, but your payments will be larger. You’re not required to complete this worksheet or reduce your withholding if you don’t wish to do so.

You can also use this worksheet to figure out how much to increase the tax withheld from your payments if you have a large amount of other income, such as interest, dividends, or capital gains.

Another option is to take these items into account and make your withholding more accurate by using the calculator at www.irs.gov/W4App. If you use the calculator, you don’t need to complete any of the worksheets for Form W 4P.

Multiple Pensions/More Than One Income WorksheetComplete this worksheet if you receive more than one pension, if you have a pension and a job, or if you’re married filing jointly and have a working spouse or a spouse who received a pension. If you don’t complete this worksheet, you might have too little tax withheld. If so, you will owe tax when you file your tax return and might be subject to a penalty.

Form W-4P (2018) Page 4

Figure the total number of allowances you’re entitled to claim and any additional amount of tax to withhold on all pensions using worksheets from only one Form W 4P. Claim all allowances on the Form W 4P that you or your spouse file for the highest paying pension in your family and claim zero allowances on Forms W 4P filed for all other pensions. For example, if you receive $60,000 from your pension per year and your spouse

receives $20,000 from a pension, you should complete the worksheets to determine what to enter on lines 2 and 3 of your Form W 4P, and your spouse should enter zero (“ 0 ”) on lines 2 and 3 of his or her Form W 4P. See Pub. 505 for details.

Another option is to use the calculator at www.irs.gov/W4App to figure your withholding more precisely.

Personal Allowances Worksheet (Keep for your records.)A Enter “1” for yourself . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A

B Enter “1” if you will file as married filing jointly . . . . . . . . . . . . . . . . . . . . . . B

C Enter “1” if you will file as head of household . . . . . . . . . . . . . . . . . . . . . . . C

D Enter “1” if: {• You’re single, or married filing separately, and have only one pension; or• You’re married filing jointly, have only one pension, and your spouse hasno income subject to withholding; or• Your income from a second pension or a job or your spouse’s pension or wages (or the total of all) are $1,500 or less.

} . . . . . D

E Child tax credit. See Pub. 972, Child Tax Credit, for more information.• If your total income will be less than $69,801 ($101,401 if married filing jointly), enter “4” for each eligible child.

• If your total income will be from $69,801 to $175,550 ($101,401 to $339,000 if married filing jointly), enter “2”for each eligible child.• If your total income will be from $175,551 to $200,000 ($339,001 to $400,000 if married filing jointly), enter “1”for each eligible child.• If your total income will be higher than $200,000 ($400,000 if married filing jointly), enter “-0-” . . . . . . E

F Credit for other dependents.

• If your total income will be less than $69,801 ($101,401 if married filing jointly), enter “1” for each eligibledependent.

• If your total income will be from $69,801 to $175,550 ($101,401 to $339,000 if married filing jointly), enter “1”for every two dependents (for example, “-0-” for one dependent, “1” if you have two or three dependents, and “2” if you have four dependents).• If your total income will be higher than $175,550 ($339,000 if married filing jointly), enter “-0-” . . . . . . F

G

Other credits. If you have other credits, see Worksheet 1-6 of Pub. 505 and enter the amount from that worksheet here . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . G

H Add lines A through G and enter the total here . . . . . . . . . . . . . . . . . . . . . H

For accuracy, complete all worksheets that apply. {

• If you plan to itemize or claim adjustments to income and want to reduce your withholding, or if you have a large amount of other income and want to increase your withholding, see the Deductions, Adjustments, and Additional Income Worksheet, later.• If you have more than one source of income subject to withholding or are married filing jointly and you and your spouse both have income subject to withholding and your combined income from all sources exceeds $52,000 ($24,000 if married filing jointly), see theMultiple Pensions/More-Than-One-Income Worksheet on page 5 to avoid having too little tax withheld.• If neither of the above situations applies, stop here and enter the number from line H on line2 of Form W-4P above.

Form W-4P (2018) Page 5

Deductions, Adjustments, and Additional Income Worksheet

Note: Use this worksheet only if you plan to itemize deductions, claim certain adjustments to income, or have a large amount of other income.

1

Enter an estimate of your 2018 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state and local taxes (up to $10,000), and medical expenses in excess of 7.5%of your income. See Pub. 505 for details . . . . . . . . . . . . . . . . . . . . . 1 $

2 Enter: { $24,000 if you’re married filing jointly or qualifying widow(er)$18,000 if you’re head of household$12,000 if you’re single or married filing separately

} . . . . . . . . . . 2 $

3 Subtract line 2 from line 1. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . . 3 $

4

Enter an estimate of your 2018 adjustments to income and any additional standard deduction for age or blindness (see Pub. 505 for information about these items) . . . . . . . . . . . . . . . 4 $

5 Add lines 3 and 4 and enter the total . . . . . . . . . . . . . . . . . . . . . . 5 $6 Enter an estimate of your 2018 other income (such as dividends, interest, or capital gains) . . . . . 6 $7 Subtract line 6 from line 5. If zero, enter “-0-”. If less than zero, enter the amount in parentheses . . 7 $

8

Divide the amount on line 7 by $4,150 and enter the result here. If a negative amount, enter inparentheses. Drop any fraction . . . . . . . . . . . . . . . . . . . . . . . . 8

9 Enter the number from the Personal Allowances Worksheet, line H, page 4 . . . . . . . . . 9

10

Add lines 8 and 9 and enter the total here. If zero or less, enter “-0-”. If you plan to use the Multiple

Pensions/More-Than-One-Income Worksheet, also enter this total on line 1 below. Otherwise, stop

here and enter this total on Form W-4P, line 2, page 1 . . . . . . . . . . . . . . . . 10

Multiple Pensions/More-Than-One-Income Worksheet

Note: Use this worksheet only if the instructions under line H from the Personal Allowances Worksheet direct you here. This applies if you (and your spouse if married filing jointly) have more than one source of income subject to withholding (such as more than one pension, or a pension and a job, or you have a pension and your spouse works).

1

Enter the number from the Personal Allowances Worksheet, line H, page 4 (or from line 10 above ifyou used the Deductions, Adjustments, and Additional Income Worksheet) . . . . . . . . 1

2

Find the number in Table 1 below that applies to the LOWEST paying pension or job and enter it here. However, if you’re married filing jointly and the amount from the highest paying pension or job is $75,000 or less and the combined amounts for you and your spouse are $107,000 or less, do not enter more than “3” 2

3 If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter “-0-”) and on Form W-4P, line 2, page 1. Do not use the rest of this worksheet . . . . . . . . 3

Note: If line 1 is less than line 2, enter “-0-” on Form W-4P, line 2, page 1. Complete lines 4 through 9 below to figure the additional withholding amount necessary to avoid a year-end tax bill.4 Enter the number from line 2 of this worksheet . . . . . . . . . . . 4

5 Enter the number from line 1 of this worksheet . . . . . . . . . . . 5

6 Subtract line 5 from line 4 . . . . . . . . . . . . . . . . . . . . . . . . . . 6

7 Find the amount in Table 2 below that applies to the HIGHEST paying pension or job and enter it here 7 $8 Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . . 8 $

9

Divide line 8 by the number of payments remaining in 2018. For example, divide by 8 if you’re paid every month and you complete this form in April 2018. Enter the result here and on Form W-4P, line 3, page 1. This is the additional amount to be withheld from each payment . . . . . . . . . . 9 $

Table 1

Married Filing Jointly

If wages from LOWEST paying job or pension are—

Enter on line 2 above

$0 - $5,000 05,001 - 9,500 19,501 - 19,000 2

19,001 - 26,500 326,501 - 37,000 437,001 - 43,500 543,501 - 55,000 655,001 - 60,000 760,001 - 70,000 870,001 - 75,000 975,001 - 85,000 1085,001 - 95,000 1195,001 - 130,000 12

130,001 - 150,000 13150,001 - 160,000 14160,001 - 170,000 15170,001 - 180,000 16180,001 - 190,000 17190,001 - 200,000 18200,001 and over 19

All Others

If wages from LOWEST paying job or pension are—

Enter on line 2 above

$0 - $7,000 07,001 - 12,500 1

12,501 - 24,500 224,501 - 31,500 331,501 - 39,000 439,001 - 55,000 555,001 - 70,000 670,001 - 85,000 785,001 - 90,000 890,001 - 100,000 9

100,001 - 105,000 10105,001 - 115,000 11115,001 - 120,000 12120,001 - 130,000 13130,001 - 145,000 14145,001 - 155,000 15155,001 - 185,000 16185,001 and over 17

Table 2

Married Filing Jointly

If wages from HIGHEST paying job or pension are—

Enter on line 7 above

$0 - $24,375 $42024,376 - 82,725 50082,726 - 170,325 910

170,326 - 320,325 1,000320,326 - 405,325 1,330405,326 - 605,325 1,450605,326 and over 1,540

All Others

If wages from HIGHEST paying job or pension are—

Enter on line 7 above

$0 - $7,000 $4207,001 - 36,175 500

36,176 - 79,975 91079,976 - 154,975 1,000

154,976 - 197,475 1,330197,476 - 497,475 1,450497,476 and over 1,540

Form W-4P (2018) Page 6

Privacy Act and Paperwork Reduction Act NoticeWe ask for the information on this form to carry out the Internal Revenue laws of the United States. You’re required to provide this information only if you want to (a) request federal income tax withholding from periodic pension or annuity payments based on your withholding allowances and marital status; (b) request additional federal income tax withholding from your pension or annuity; (c) choose not to have federal income tax withheld, when permitted; or (d) change or revoke a previous Form W-4P. To do any of the aforementioned, you’re required by sections 3405(e) and 6109 and their regulations to provide the information requested on this form. Failure to provide this information may result in inaccurate withholding on your payment(s). Providing false or fraudulent information may subject you to penalties.

Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation, and to cities, states, the District of Columbia, and U.S. commonwealths

and possessions for use in administering their tax laws. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.

You’re not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by section 6103.

The average time and expenses required to complete and file this form will vary depending on individual circumstances. For estimated averages, see the instructions for your income tax return.

If you have suggestions for making this form simpler, we would be happy to hear from you. See the instructions for your income tax return.

REFER TO INSTRUCTIONS ON OPPOSITE PAGETYPE OR PRINT IN INK

MEMBER’S INFORMATIONFirst name Middle initial Last name SSN (last 4 digits)

Street address Date of birth

City State Zip code Weekday telephone number

Any death benefits payable by State Employees’ Retirement System shall be paid in EQUAL SHARES to the following beneficiary(ies) who survive me.

Beneficiary name (last, first, middle initial) Street Address SSN (last 4 digits) (optional)

Relationship / Phone number City, State, Zip code Date of Birth (MM/DD/YYYY)

In the event all primary beneficiaries die before me, the death benefit shall be paid in EQUAL SHARES to the following secondary beneficiary(ies) who survive me.

Beneficiary name (last, first, middle initial) Street Address SSN (last 4 digits) (optional)

Relationship / Phone number City, State, Zip code Date of Birth (MM/DD/YYYY)

By signing below, I certify that I am aware that knowingly making a false statement or falsifying a record in attempt to defraud SERS is a class 3 felony. I understand that if the SERS Board of Trustees has a reasonable suspicion that an attempt has been made to defraud SERS, it will report the matter to the appropriate State’s Attorney for investigation.

Signature (Do not print) Date signed

PR

IMA

RY

SE

CO

ND

AR

YState Employees’ Retirement System2101 S. Veterans Pkwy P.O. Box 19255Springfield, IL 62794-9255217-785-7444Fax: 217-524-1621

101 (R 9-17) IL 589-0111

Death Benefit Beneficiary Designation

Beneficiary Designation Instructions

This form is used to designate beneficiaries to receive any lump-sum death benefits payable from the State Employees’ Retirement System (SERS) in the event of your death. If you do not designate beneficiaries, death benefits will be paid to your estate. The Death Benefit Beneficiary Designation Form does not pertain to survivor benefits or life insurance proceeds.

This form should be typed or printed clearly in ink. Cross through and initial any corrections or changes. Do not use correction fluid.

Payment progression: Your death benefits will be paid first to your primary beneficiaries. If some of your primary beneficiaries die before you, your death benefit will be divided among those primary beneficiaries who are still living. Secondary beneficiaries will receive benefits only if no primary beneficiary survives you.

If you specify percentages to be paid to beneficiaries in either the primary or secondary designation areas, the percentages in each category must total 100%. If you choose to designate specific percentages, please write the percentage next to each name.

Please provide all of the requested information for each designated beneficiary, including the date of birth and last four digits of the Social Security number as this information will help SERS locate your beneficiaries. If you want to name your estate as beneficiary, write the word “Estate” on the Death Benefit Beneficiary Designation Form. It will be the responsibility of your executor to distribute the proceeds as outlined in your will.

If you need additional space for primary or contingent beneficiaries, attach a signed and dated sheet listing additional beneficiaries, including all details, as indicated in Beneficiary Designation section.

DO NOT return this form to your agency. The beneficiary designation must be returned to SERS and becomes effective when received and deemed valid by SERS. Invalid forms will be returned with further instructions. Any form received by SERS after the member’s date of death will be invalid.

You may change beneficiaries at any time by completing a new Death Benefit Beneficiary Designation Form. The form on file at SERS that has the most recent date located next to the member’s signature will take precedence.

Once you have completed your designation and signed and dated the form, it must be mailed or sent by facsimile to SERS. DO NOT email this form to SERS. Email is not secure and puts your personal information at risk.

A person with Power of Attorney may sign a Death Benefit Beneficiary Designation Form on behalf of a member. They must also submit a copy of the Power of Attorney papers and the papers must specifically state that the person with Power of Attorney has the right to name and/or change the beneficiaries for the member.

An acknowledgement will be sent to active and inactive employees upon receipt of a valid designation. Retirees will be notified of a valid designation on their annual benefit statement.

S E R S S U R V I V O R B E N E F I T SIf an SERS member contributed to SERS and Social Security, a benefit offset could be applied to the SERS widow or survivor ben-efit when the survivor becomes eligible for Social Security benefits.

Social Security Election at RetirementEffective July 1, 2009, retiring SERS members will have the OPTION to remove the Social Security offset when completing their retire-ment application. SERS will reduce the mem-ber’s retirement annuity by 3.825% monthly in retirement.

Death Before RetirementIf you die while actively employed and have atleast 18 months of service credit, your qualifiedsurvivors will be eligible for survivor benefits. In addition to survivor benefits, your pension contributions and interest, will also be paid to your named beneficiary(ies). If you die with no qualified survivors whileactively employed, your named beneficiary(ies)will receive your contributions, plus interest, and one month’s salary for each year of service, up to a maximum of six months’ salary.

Death After RetirementIf you die after retiring, survivor benefits aresubject to the same maximums as those payableduring active employment, or 80% of the pen-sion you were receiving when you died, which-ever is less. If 50% of your pension provides a greater monthlybenefit than the amounts stated above, it is payableto your survivors. If you have no survivors, your beneficiary(ies) will receive any remaining contributions and interest, or $500, whichever is greater. The Social Security offset applies to coordinated members.

Survivor PaymentsSERS will process your first annuity paymentafter we receive your application and other required information. The normal processing time is 30 days. The Comptroller’s Office will mail the first annuity payment directly to your home. Future annuity payments are mailed on the 19th of each month, unless the 19th is on a weekend or holiday, when they are mailed on the last working day before the 19th. If your payment is mailed directly to your home, allow ten working days for delivery. If you receive a monthly survivor annu-ity, you will receive a 3% increase on January 1 following one full year of payments. Future increases of 3% will be made each January 1 thereafter.

Taxation of Survivor BenefitsAll SERS benefits are exempt from state incometax under Illinois law. If your federal tax with-holding information is not on file with SERS, taxes are withheld using the rate for a married person with three exemptions.

Survivor EmploymentThe only employment restriction for individualsreceiving a survivor, widow, or occupationaldeath benefit from SERS is for disabled, unmar-ried children over age 18. This benefit is payable if the disabled child is not gainfully employed and earning more than $2490 per quarter.

Lump Sum Death Benefits After RetirementIf a retired SERS member dies with no payablesurvivor annuity, the nominated beneficiary (ies) receive any contributions and interest remaining in the retiree’s account, or $500, whichever is greater.

Survivor Questions & Answers

Are my surviving children and dependent par-ents subject to the Social Security offset?The Social Security offset applies to any survi-vor benefits being paid to your qualified sur-vivors. If you participate in the Social Security election, your qualified survivors will receive the full SERS survivor benefit as well as the full Social Security survivor benefit.

Should I participate in the offset provision?If your survivor has done very little work in a position covered by Social Security, this option gives you a chance to provide a better monthly income for your survivor because the Social Security offset will no longer apply to the SERS survivor benefits.

At the time of my death, how long will my eli-gible survivor receive monthly benefits?A survivor remains eligible to receive benefits until death. A child remains eligible until age 18 (22 if attending school full-time), or the child marries. Disabled adults may continue to receive benefits as long as their disability con-tinues and they aren’t gainfully employed or married.

If my spouse is my qualified survivor and is employed when I die, could (s)he receive survi-vor benefits and continue working?Yes, your spouse may work and qualify for sur-vivor benefits.

Eligible Survivors Benefits

For All Survivor Benefits: If 50% of your earned pension provides a greater monthly benefit than the amounts stated below, the higher amount is payable to your spouse.

Your Spouse: If you are survived by your spouse age 50 or over, and you were married at least one year prior to your death, your spouse will receive $1,000, plus a monthly annuity until their death.

Your Spouse and Children: If your spouse supports your children under age 18 (22 if full-time student), or a disabled child over 18, your spouse can receive benefits before age 50. They will receive $1,000, plus a monthly annu-ity. This benefit is payable until your last child reaches age 18 (22 if full-time student), marries, dies, or is no longer disabled.

Your Children: If you are not survived by a spouse, but have children under age 18 (22 if full-time student), or over 18 and disabled, they can receive $1,000, plus a monthly annuity. This benefit is payable until the last child reach-es age 18 (22 if full-time student), marries, dies, or is no longer disabled.

Your Dependent Parents: If your spouse or children do not survive you, your dependent parents may be eligible for benefits.

Part I - General Information (Please Type or Print)

Name of Payee Social Security Number of Payee

Address of Payee / Apt. or P.O. Box City State Zip

Home/Cell Telephone Number Email Address

Part II - Acknowledgment of Responsibilities (to be completed by Payee)I, the above-designated Payee, am receiving a monthly benefit from the State Employees’ Retirement of Illinois (SERS). I hereby authorize SERS to forward such payments by electronic fund transfer to the financial institution indicated below and the financial institution to credit the amounts thereof to the account listed below.

I hereby acknowledge that my monthly benefits terminate at the end of the month of my death or my eligibility period. Accordingly, I agree that if any benefit payments to which I am not entitled shall have been received and collected by my financial institution, I or we (if my account is a joint account) hereby authorize and direct my financial institution to refund the same to SERS and charge such refund payments to the account listed below or any other account of mine, or to the extent money has been withdrawn from the account listed below by any other of the undersigned, to charge such refund payments to any other account which we, individually or jointly, may have in such financial institution.

I further direct my financial institution to immediately notify SERS of the names and addresses of any and all joint account holders that may be added to my account at a future date. I or we (if my account is a joint account) further agree to hold harmless my financial institution for any action taken pursuant to or in compliance with this depository agreement.

This authority is to remain in full effect until my death or the end of my eligibility period, or until SERS has received notification from me of its termination in such time and manner as to afford a reasonable opportunity to act on it, or until SERS has sent me a ten (10) day advance written notice of SERS termination of this arrangement.

Signature of payee, power of attorney (attach document), or guardian (attach court order) Date

Signature of joint account holder, if any Date

Signature of joint account holder, if any Date

Note: All persons having an interest in the above account must sign.

FINANCIAL INSTITUTION INFORMATIONPart III - Acceptance of financial institution (to be completed by financial institution). The undersigned, on behalf of the financial institution below, hereby accepts the depository agreement as set forth above and verifies the signatures of all persons having an interest in the account.

Name of Financial Institution Account Holder Name(s)

Address Branch Designation, if Applicable

City/State/Zip

Telephone Number

Signature of Authorized Official Date

Title A.C.H.Routing Number The last number of the routing number is the check digit

Checking Account Savings Account

Account Number Information

3967 (R-9-17)

STATE EMPLOYEES’ RETIREMENT OF ILLINOIS2101 South Veterans Parkway, P.O. Box 19255Springfield, IL 62794-9255, Phone: 217/524-8806

Check box if this account currently receives Direct Deposit from State of Illinois.

Certification: By signing, I certify that this information is correct. I am aware that pursuant to the Illinois Pension Code, 40 ILCS 5/-135, any person who knowingly makes any false statement or falsifies or permits to be falsified any record in an attempt to defraud SERS is guilty of a Class 3 felony. I am aware that the SERS Board has reasonable suspicion that a false record has been filed with SERS it is required to report the matter to the state’s attorney for investigation.

DEPOSITORY AGREEMENT FOR SERS BENEFIT PAYMENTS

THE DIRECT DEPOSIT PROGRAM IS RELIABLE, SAFE AND CONVENIENT!l Your money is electronically deposited to your account and available for your use on the morning of the transfer

date.l No need to worry about lost, stolen or misplaced checks.l You avoid receiving your benefit payment late.l If you choose Direct Deposit, your first payment is mailed to your home. All future payments are electronically

deposited into your account on the 19th of each month.l If you receive more than one type of benefit from State Employees’ Retirement System of Illinois (SERS), these

funds may only go to one designated bank account.

INSTRUCTIONS

THE TERMS OF THIS DEPOSITORY AGREEMENT MAY NOT BE AMENDED BY ANY PARTY.SERS through the Office of the Comptroller has the ability to electronically deposit a payee’s monthly benefit to an authorized participat-ing Automated Clearing House (ACH) Network financial institution. The financial institution may be any bank, savings bank, savings and loan association or similar institution, or federal or state chartered credit union in which the payee has a checking or savings account participating in the ACH Network. In order for SERS to deposit the payee’s monthly benefit into a financial institution, the payee, any joint account holder, and the financial institution must complete this form.

PART I - PAYEE INFORMATIONThe payee’s name, social security number, address, home/cell telephone number, and alternate telephone number, if any, should be typed or printed in the appropriate boxes.

PART II - ACCOUNT HOLDER AGREEMENTAfter reading the conditions of the depository agreement, the payee, power of attorney, or guardian must sign and date the form. If a power of attorney signs the form on behalf of the payee, the power of attorney document must be attached to the form. If a guardian signs the form on behalf of the payee, letters of office or other similar court document must be attached if the guardian is not the natural parent of the payee. If there are one or more joint account holders, all joint account holders must sign and date the form.

PART III - FINANCIAL INSTITUTION AGREEMENTThe selected financial institution should complete all of the information requested in Part III. The monthly benefit may only be deposited in an account in which the payee has an interest. The routing number should reflect the number for electronic transfers which may be different from the routing number for the branch bank at which the account is held. The payee, by signing this form, authorizes the financial institution to communicate to SERS concerning the parties who have an interest in the account and to recover erroneous pay-ments from the account holders. By an authorized individual signing this form, the financial institution agrees to accept the electronic transfer from SERS on behalf of the payee and verifies the signatures of all persons having an interest in the payee’s account.

Upon completion of the form by account holders and financial institution, return to SERS by mail or facsimile for processing.

l Once your bank information is updated in the SERS system, you will receive notification that your next check will be processed electronically.l You can securely view your monthly earnings statement through the SRS Members Services website. To view your account

information, you may register through our website at srs.illinois.gov and navigate to the link “view PDF version on how to secure and ID”. You will find the instructions for the one-time registration process that must be completed to access your account information online.

TERMINATION OF DEPOSITORY AGREEMENTThis depository agreement shall remain in effect until terminated by:

l the death of the payee or the end of payee’s eligibility period;l cancellation by the payee, power of attorney, or guardian by written notice to SERS in such time and manner as to

afford SERS a reasonable opportunity to act upon such notice;l a ten (10) day advance written notice from SERS to the Payee indicating SERS’ termination of the agreement; orl the closing of the account by the payee or the financial institution.

The amount of any payments received after termination should be returned to SERS by the financial institution or an account holder, along with a statement including the name of the payee, the payees’s social security number and the date of the errone-ous deposit.

GROUP INSURANCE BENEFITSNow that you are retiring, the Group Insurance Section of SERS will be assisting you with your group insurance needs. In order to properly maintain your insurance records, please keep your address and phone number current with the State Employees’ Retirement System. For up-to-date information, rates, publica-tions, contact information and the latest news about what is going on with the Group Insur-ance Program, visit our website at www.srs.il-linois.gov. Click on “State Employees’ Retirement System” then click on “Insurance” located on the right side of the screen.

INSURANCE INFORMATION AT RETIREMENTTo qualify for the State of Illinois Group Insur-ance Program, a member must be receiving a monthly check from the State Employees’ Re-tirement System (SERS). Eligible members must be vested in SERS (Tier 1 employee: 8 Years; Tier 2 employee: 10 years) for eligibility into the Group Insurance Program. Members must also complete and sub-mit the required Insurance Participation Elec-tion Form, found in the pension packet. Insurance coverage becomes effective on the date of commencement of the monthly benefit, the first of the month that the application for retirement was received, or the first day of the month that the group insurance enrollment form was received, whichever is later. The member health insurance premium is state-paid for members with 20 or more years of service. For members with less than 20 years of service, the state will pay 5% of the state cost for health insurance for each full year of ser-

vice. The member will pay the balance. Premiums for dependent health coverage, as well as member and dependent dental coverage are available in the most current Benefit Choice Booklet which is available on our website at www.srs.illinois.gov

MEDICARE IN RETIREMENT Medicare is a federal health insurance program for individuals 65 and older, individuals under age 65 with certain disabilities and individuals of any age with End Stage Renal Disease. The State of Illinois Group Insurance Pro-gram requires retired or disabled plan partici-pants who become eligible for premium-free Medicare Part A (hospitalization) to enroll in Medicare Part B (outpatient services including physician office visits, labs, x-rays and some medical supplies). If you are not sure if you qualify for pre-mium-free Medicare Part A, contact your local Social Security Office. If a retiring or disabled plan participant fails to purchase Part B of Medicare once they become eligible for premi-um-free Part A, the State will reduce its benefits by what Part B would have paid. This reduction will result in additional out-of-pocket expenses to the member. If a member and/or the member’s depend-ent(s) are not eligible for premium-free Part A of Medicare, the State will pay your health in-surance claims at the normal benefit level with no reduction. State health insurance premiums are lower for Medicare-prime (enrolled in both Part A and Part B of Medicare) dependents. The SERS Insur-ance Section requires a letter from the Social Security Administration verifying ineligibility for premium-free Medicare Part A.

If you and/or your dependents receive or have Medicare cards from the Social Security Administration, please send a copy of the card(s) to the SERS Insurance Section to ensure your insurance is coded to avoid claim and/or pre-mium errors. Deductibles for retirees and other insurance information can be found at the SERS website (www.srs.illinois.gov); simply click on the Insur-ance Information Link.

GROUP LIFE INSURANCE AT THE TIME OF RETIREMENTIf you are age 60 or older at retirement, the basic life insurance amount reduces to $5,000. When the basic life amount is reduced to $5,000 and you had elected “optional” life cov-erage, the optional life coverage will also reduce to increments of $5,000, up to a maximum of four times the Basic amount.

GROUP LIFE INSURANCE BENEFICIARYState life insurance beneficiary designations are maintained by Minnesota Life Insurance Com-pany, the current life insurance administrator for the State of Illinois. If you have not designated a beneficiary or wish to change a beneficiary designation, contact Minnesota Life at 1-888-202-5525.

NOTE: Your Group Life Insurance beneficiary is separate from your SERS Death Benefit beneficiary.

T R A I LTotal Retiree Advantage

Illinois Medicare Advantage Program

The TRAIL Enrollment Period is held each fall with an effective date of January 1st of the fol-lowing year. For more information regarding the Medicare Advantage “Trail” Program, go to www.cms.illinois.gov/thetrail. To be included in the TRAIL Medicare Ad-vantage program, all dependents covered by the member’s State insurance must also be enrolled in Medicare Part A and B. In order to be in-cluded in the fall TRAIL Enrollment Period, the member and all dependents must have acquired Medicare Part A and B on or prior to September 30th of that year. CMS will determine who will participate in the Medicare Advantage Enroll-ment.

M E D I C A R E I N S U R A N C EM E D I C A R E I N S U R A N C Efor Retired SERS Members & Eligible Dependents

WHAT IS MEDICARE?

Medicare is a federal health insurance program for the following:

• People age 65 or older

• People under age 65 with certain disabilities

• People of any age with End-Stage Renal Disease (ESRD)

Medicare consists of the following parts to help cover specific services:

Part A (Hospital Insurance): a premium-free benefit for participants with enough earned credits based on their own work history or that of a spouse (when applicable).

Part B (Outpatient/Medical Insurance): a premi-um-driven benefit and a requirement for par-ticipants in the State Plan who are eligible for premium-free Part A.

Part D (Prescription Drug Insurance): a premi-um-driven benefit (unless the participant quali-fies for extra help assistance) and is not required for participants in the State Plan.

In order to apply for Medicare benefits, partici-pants are instructed to contact their local Social Security Administration (SSA) office or call

1-800-772-1213. Participants may also contact the SSA via the internet at www.socialsecurity.gov to enroll in Medicare Part A.

RETIRED STATE PARTICIPANTS (AND APPLICABLE DEPENDENTS)The State of Illinois requires plan participants who become eligible for premium-free Medi-care Part A due to age (upon turning age 65) or due to disability (under age 65) to enroll in the Medicare Program. Medicare is the primary payer for health in-surance claims for retired participants enrolled in both Medicare (due to age or a disability) and the State Group Insurance Program. Medi-care may not be the primary insurer if a third insurance carrier is involved. When Medicare is deemed the primary payer, enrollment in both Medicare Parts A & B is required. Failure to enroll and maintain enrollment in Parts A & B when Medicare is determined to be the primary insurance payer, results in a reduction of benefits under the State of Illinois Group Insurance Plan. This will result in ad-ditional out-of-pocket expenses for medical-related services!

Plan participants who are eligible for Medicare or who become eligible for Medicare benefits are required to

submit a copy of their Medicare identification card to SERS or the

State of Illinois Medicare COB Unit.

EMPLOYMENT OUTSIDE STATE GOVERNMENTRetirees, survivors and applicable dependents who have current employment elsewhere (with insurance through the current employer or through a spouses’s current employer) or par-ticipants enrolled in Medicare on the basis of ESRD should contact the State of Illinois Medi-care Coordination of Benefits (COB) Unit for the appropriate benefit coordination.

QUESTIONS?If you have questions about Medicare or how it coordinates with the State of Illinois Group Insurance Program:

Central Management ServicesMedicare Coordination of Benefits UnitP. O. Box 19208Springfield, IL 62794-9208217-782-7007 OR1-800-442-1300 ext. 7007

STATE RETIREMENT SYSTEMS

State Employees' Retirement System of Illinois General Assembly Retirement SystemJudges' Retirement System of Illinois

2101 South Veterans Parkway, P.O. Box 19255, Springfield, IL 62794-9255

Internet: http://www.srs.illinois.gov E-Mail: sers@srs.illinois.gov

Retiree Insurance Form

Please note that THIS IS A REQUIRED FORM if you meet the service eligibility requirement below. Failure to submit this form could delay the ability to enroll or make changes to your insurance. See the enclosed form (3018) for insurance benefit instructions.

Insurance Eligibility Service RequirementMembers who have completed 8 years of qualifying service under SERS (Tier 1 employees) are eligible to participate in the State of Illinois Group Insurance Program at the time of their retirement.

NOTE: If you do not meet the above requirement, you are NOT eligible to participate and should not complete this form.

Members retiring with 20 or more years of service will receive premium free member health insurance.

Members retiring with a minimum of 8 years, but have less than 20 years of qualified service, will be required to share the cost of their health insurance coverage. For each full year of qualified service, the State will contribute 5% toward the cost of the member’s insurance. Visit (www.srs.illinois.gov) or (www.mybenefits.illinois.gov) for rates.

NOTE: Premiums for dental and dependent coverage are additional.

Name: ______________________________________________________________________ Date of Birth________________________

Residential Street Address: ________________________________________________________________________________________

City: _____________________________________________________________________ State: _________ Zip: __________________

Mailing Address: _________________________________________________________________________________________________

City: ____________________________________________________________________ State: __________ Zip: __________________

Member ID# or last 4 of SSN: _____________________________ Email Address: _________________________________________

Telephone number: _______________________________________ Alternate telephone number: ____________________________

Last date worked:________________________________________ Date of retirement: ______________________________________

IF APPLICABLE: Attach a copy of medicare card for member and covered dependents.

Opt Out Financial Incentive (20 years/$500 per month, Less than 20 years/$150 per month): If you are Not eligible for Medicare and elect to opt out of the insurance program to receive a monthly incentive check, mark the following box.

NOTE: Effective date of the incentive is based on date of receipt of the required forms.

I elect to opt out for the incentive and request an incentive packet be mailed. (Minimum of 8 years of SERS service required)

Date Sent (By email or U.S. Mail)______________________ GIR Intials__________

I elect to opt out without the incentive. (See form 3018, section A., #5, for instruction.)

Member currently enrolled as a dependent I am currently enrolled as a dependent on my state-covered spouse’s or civil union partner’s health, dental and vision insurance cover-age for at least one year, and therefore, qualify to remain on my spouse’s or civil union partner’s state insurance as a dependent. I understand that waiving my coverage as an annuitant to remain a dependent of my spouse/civil union partner will mean that the only coverage I will have as an annuitant (member) will be life insurance coverage.

Signature: _________________________________________________________ Date:___________________________

(if different than Street address)

3991 (R - 10-17)

STATE RETIREMENT SYSTEMS

State Employees' Retirement System of Illinois General Assembly Retirement SystemJudges' Retirement System of Illinois

2101 South Veterans Parkway, P.O. Box 19255, Springfield, IL 62794-9255

Internet: http://www.srs.illinois.gov E-Mail: sers@srs.illinois.gov

State Life Insurance and Medicare Information

Life Insurance: If you are retiring within one year of terminating state employment and you are under age 60, your life insurance will remain as it was as an active employee. Once you turn age 60 (retired) your basic life insurance will reduce to $5,000 and any optional life insurance you carry will reduce by increments of $5,000. Spouse Life Insurance will reduce to $5,000. Child Life will remain at $10,000. Members retiring at age 60 or above who will experience a reduction in life insurance coverage at the time of their retirement can contact Minnesota Life at 888-202-5525 to discuss conversion or portabil-ity options.

If you are retiring after one year of terminating state employment, you are eligible for basic life insur-ance only.

Medicare Information:Medicare is a federal health insurance program for individuals 65 and older, individuals under age 65 with certain disabilities and individuals at any age with End Stage Renal Disease.

The State of Illinois Group Insurance Program requires retired or disabled plan participants who be-come eligible for premium-free Medicare Part A (hospitalization) to enroll in Medicare Part B (outpa-tient services including physician office visits, labs, x-rays and some medical supplies).

If you are not sure if you qualify for premium-free Medicare Part A, contact your local Social Security Office. If a retiring or disabled plan participant fails to purchase Part B of Medicare once they become eligible for premium-free Part A, the State will reduce its benefits and the member will pay the portion that Medicare would have paid. This reduction will result in additional out-of-pocket expenses to the member.

If a member and/or the member’s dependent(s) are not eligible for premium-free Part A of Medicare, the State will pay your health insurance claims at the normal benefit level with no reduction. The SERS Insurance Section requires a letter from the Social Security Administration verifying ineligibility for premium-free Medicare Part A.

State health insurance premiums are lower for Medicare-prime (enrolled in both Part A and Part B of Medicare) dependents.

If you and/or your dependents receive or have Medicare cards from the Social Security Administration, please send a copy of the card(s) to the SERS Insurance Section to ensure your insurance is coded to avoid claim and/or premium errors.

Questions about Medicare should be directed to the CMS Medicare Unit at 217-782-7007.

CAREFULLY REVIEW YOUR PENSION CHECK TO ENSURE DEDUCTIONS ARE CORRECT

3973 (R 9-17)

STATE RETIREMENT SYSTEMS

State Employees' Retirement System of Illinois General Assembly Retirement SystemJudges' Retirement System of Illinois

2101 South Veterans Parkway, P.O. Box 19255, Springfield, IL 62794-9255

Internet: http://www.srs.illinois.gov E-Mail: sers@srs.illinois.gov

Welcome to the State Employees’ Retirement System (SERS). SERS is committed to assisting you through the retirement process for an easy transition to a new and exciting chapter of your life.

MyBenefits will assist retirees with insurance questions, choices and changes through a customized website and call center. If you do not have access to a computer, the MyBenefits call center staff will assist you by telephone.

A. Instructions:

1) Complete the Group Insurance Informational Form (3991) from the pension packet. This is a required form that you must complete and return to SERS.

2) Once the 3991 is received at SERS, we will process the form and notify Morneau Shepell of your retirement.

3) Morneau Shepell will send you an email (if provided on the 3991) or will mail you a letter to verify they have received notification of your retirement.

4) If you are satisfied with your current coverage, you don’t need to do anything.

5) If you wish to make a change to existing coverage, opt out or enroll, contact My Benefits at 1-844-251-1777 or log on to mybenefits.illinois.gov.

If you choose the opt-out incentive you must go through SERS for this benefit. See Form 3991 for more information.

B. The website (mybenefits.illinois.gov) will allow you to:1) Register.2) Make changes to your insurance at retirement, during open enrollment periods,

or changes due to qualifying events (such as adding or terminating dependents, enrollment or termination of plans, etc.).

3) View plans, premium costs, and other information.4) Use tools to determine the best plan for you and your family.5) Download forms and upload forms that are required to make your desired changes.

C. If you do not have access to a computer, contact MyBenefits at:1) 1-844-251-1777 (1-844-251-1778 (TDD/TTY)

D. You will continue to:1) Contact SERS for address changes.2) Contact SERS about Power of Attorney/Guardian documents.3) Contact SERS with questions about your retirement information, retirement check and

other deductions. 4) Contact SERS about opt-out with financial incentive.

3018 (R - 10-17)

State Insurance Instruction Sheet

In this brochure, employee contributions gen-erally refer to:

• Contributions made to SERS before January 1, 1982.

• Interest on the repayment of contributions.

• Contributions made for optional service purchases.

FEDERAL & STATE INCOME TAX WITHHOLDING

State Income Tax WithholdingAll benefits paid by SERS are exempt from Illinois income tax withholding.

Federal Income Tax Withholding Monthly PaymentsOther than occupational disability benefits, all monthly payments (periodic distributions) made by SERS are subject to federal income tax withholding in accordance with Federal Withholding Tables. When you apply for a benefit, you will be asked to com-plete a W-4P for income tax withholding. You may elect not to have withholding taken, or to have withholding taken at any level. If you do not indicate a preference for withholding, SERS must withhold at the rate for a married person with three exemptions. You may change your withholding or discontinue withholding at any time. Lump Sum PaymentsOther than occupational disability benefits, all lump sum payments (nonperiodic distributions) are sub-ject to federal income tax withholding. Withholding may be avoided in certain cases by rolling-over the payment. (see the Rollovers section.) If you or your spouse are receiving a payment that is eligible for direct transfer to another qualified em-ployer plan [401(a), 403(b)or 457 ] or an IRA or Roth IRA (Individual Retirement Account or Annuity), and

you do not ask SERS to do a direct transfer, the lump sum payment is subject to a 20% federal withhold-ing rate. You or your spouse may not rollover the non-taxable portion of the lump sum payment to a 457 plan (Deferred Compensation). You may rollover the non-taxable portion of a lump sum payment to a qualified employer plan or to a 403(b) plan. Any rollover of the non-taxable portion of a lump sum payment to a qualified plan or 403(b) plan must be a direct transfer, and the plan where the rollover is made must separately account for after-tax contributions (and earnings thereon).

FEDERAL & STATE INCOME TAXES

Taxation of a Retirement Annuity Retirement annuities (pensions) paid by SERS are ex-empt from Illinois income tax. Pension payments are subject to federal income tax under the Simplified Method. This method states that a portion of each benefit payment is taxable, and a portion is nontax-able based on the recovery of employee contribu-tions and the age of the individual. Following the recovery of the employee contributions, the entire benefit payment and any increase to the benefit is taxable. The amount of the monthly benefit that is nontax-able will be provided when the benefit begins. A form 1099-R will be issued each January. If you die with no eligible survivor or nominated beneficiary to receive any death benefits that may be payable, any remaining employee contributions may be claimed as a miscellaneous itemized deduction (not subject to the 2% floor) on your final tax return.

Tax Credit for the Elderly A tax credit based on retirement income is avail-able for eligible state retirees under age 65 who are permanently and totally disabled. The tax credit may be applied to reduce the tax liability, if any, on the retired person. Consult your local IRS office for as-sistance in computing this credit.

TAX INFORMATION

Tax Credit for Public Safety Officers The Pension Protection Act of 2006 allows retired public safety officers to deduct up to $3,000 in pre-miums for health insurance coverage from their gross annual income. For more information, refer to IRS Publication #575 and the instructions for completing your IRS Form 1040.

Taxation of Disability Benefits Occupational disability benefits paid by SERS are exempt from federal and Illinois income tax. Al-though exempt, these benefits are reportable and a form 1099-R will be issued each January. Nonoccu-pational disability and temporary disability benefits are exempt from Illinois income tax. However, these benefits are subject to federal income tax, so a form 1099-R will be issued each January.

Taxation of Widow’s/Survivor’s BenefitsBoth lump sum and monthly widow’s/survivor’s benefits paid by SERS are exempt from Illinois in-come tax, but these benefits are subject to federal income tax. Employee contributions paid by SERS as a death benefit before retirement are excluded from taxable income. Contributions made after December 31, 1981 and interest on all contributions are included in taxable income and are eligible for a rollover when paid to a surviving spouse (see Rollovers section). These amounts are also eligible for rollover when paid to a beneficiary other than a spouse. When the benefit begins, SERS furnishes the beneficiary with the non-taxable amount, if any. The monthly benefit paid to a survivor or widow, as well as the $1,000 lump sum survivor benefit and the $500 lump sum widow’s benefit, are subject to federal income tax under the Simplified Method. This method states that a portion of each payment is taxable, and a portion is nontaxable based on the recovery of employee contributions and the annui-tant’s age. Following the recovery of the employee contribu-tions, the entire benefit is taxable. Any increase to the benefit is also taxable. Following the death of the survivor or widow, if there is not an eligible nominat-

ed beneficiary to receive any death benefits that may be payable, any remaining employee contributions may be used as a deduction on the final tax return of the survivor or widow. The portion of the monthly benefit that is nontaxable will be provided when the benefit begins. A form 1099-R will be issued each January. Taxation of Occupational Death Benefits Occupational death benefits, excluding the lump sum portion, are exempt from both federal and Il-linois income tax. The occupational death lump sum payment consists of all contributions and interest in the member’s account. Contributions and interest are subject to federal income tax and are eligible for rollover (see the Rollovers section).

Taxation of Lump Sum Payments Lump sum (nonperiodic) payments include:

• Nonoccupational death benefit

• Nonoccupational death benefit after retirement

• Widow’s/survivor’s contribution refund

• Refund of contributions

• Alternative formula contribution refund.

All lump sum payments from SERS are exempt from Illinois income tax, but are subject to federal income tax. The amount of the lump sum payment subject to income tax includes a member’s contributions made after December 31, 1981, and interest on all contri-butions (see the Rollovers section). A form 1099-R will be issued in January following the year in which payment is made.

Rollovers The Internal Revenue Code permits you to avoid taxation and federal income tax withholding on a lump sum payment by “rolling-over” the payment. The payments eligible for rollover are:

• Nonoccupational death benefit before or after retirement when paid to a spouse.

• Nonoccupational death benefit before or after retirement when paid to a beneficiary other than a spouse (for distributions after 12-31-06).

• Widow’s/survivor’s contribution refund. • Alternative formula contribution refund.

• Refund of contributions.

The lump sum payment may be rolled over to anoth-er qualified employer plan that accepts rollovers, or to an IRA or Roth IRA. The non-taxable portion may be rolled over if you ask SERS to do a direct transfer. If the non-taxable portion of the lump sum is rolled over to another qualified plan or 403(b) plan, the plan must also agree to separately account for the non-taxable portion of the rollover. If you ask SERS to do a direct transfer rollover to a qualified employer plan, traditional IRA or 403(b), you may defer taxation on the taxable portion and avoid federal income tax withholding (special IRS rules apply). If you roll over to a Roth IRA, you will be taxed on the amount rolled over. If you are 59 1/2 at the time of the rollover, the 10% additional income tax will not apply. If you do not ask SERS to transfer the payment directly to another qualified employer plan, IRA or 403(b), 20% of the taxable payment will be withheld as federal income tax and the balance will be mailed to you (see the Federal Income Tax Withholding section). You may also be eligible to use the capital gains treatment, or the ten-year averaging method to determine your taxes. If you do not ask SERS to do a direct transfer, you can still do a rollover of the payment to another qualified employer plan or IRA within 60 days of receiving the payment. You are permitted to rollover the entire payment, including the 20% that was withheld, but you will have to find other money to contribute to the IRA to replace the 20% withheld. You can also rollover the 80% you received, and be taxed on the 20% withheld from your payment. You or your spouse may not rollover the non-taxable por-tion of a lump sum payment to a 457 plan (Deferred Compensation). If you apply for a lump sum payment that is eli-gible for rollover, additional information regarding the IRS rollover rules is provided with your payment application.

Capital Gains & Ten-Year Averaging The ten-year averaging method and the capital gains provisions for lump sum payments has been repealed. However, a transition rule applies to you, your spouse, trust, or estate if you were age 50 before January 1, 1986. This rule allows ten-year averaging at 1986 tax rates, and capital gains treat-ment at a 20% tax rate. The averaging method may not be chosen unless you participated in SERS for at least five years. The five-year participation rule does not apply to death benefit distributions. If you were not age 50 before January 1, 1986, the capital gains treatment may not be used.

10% Excise Tax on Distributions Before Age 55 A refund of contributions after termination of em-ployment before age 55, is subject to a 10% excise tax. This tax does not apply to a refund of contribu-tions following termination of employment after age 55, or to death or disability. Effective August 17, 2006, this tax does not apply to distributions to employees who provide police protection, firefighter services, or emergency medical services following termination after age 50. The portion of the refund of contributions subject to the 10% excise tax is the refund paid in excess of the employee’s contributions that are not rolled-over (see the Rollovers section).

FEDERAL ESTATE TAX AND ILLINOIS INHERITANCE TAX Federal Estate Tax SERS death benefits may be subject to federal estate tax. See IRS form 706.

Illinois Inheritance Tax Illinois Inheritance Tax will not apply to benefits paid by SERS. An estate tax will be imposed if your tax-able estate exceeds the permitted filing requirement. This tax will be equal to the amount of the credit al-lowable under federal estate tax laws for state death taxes.