Disability retirement handbook [2007]

Disability Retirement Handbook
Everything you need to apply for retirement

what's Everything You Need to Know About
inside Applying for TRS Disability Retirement

letter from the director 2

retirement checklist

3

retirement factsheet

4

health & dental benefits

6

retirement plans

7

types of creditable service 10

unused sick leave credit 13

working after retirement 15

glossary of terms

16

application for disability retirement 21

physicians report

25

member's list of disability info 27

psychiatrist/psychologist/counselor report 29

hospital/clinic report

33

designation of multiple beneficiaries 35

sick leave certification

37

retirement certification report 39

tax information and forms 42

TEACHERS RETIREMENT SYSTEM OF GEORGIA
Two Northside 75 Suite 100 Atlanta, GA 30318 (404) 352-6500 (800) 352-0650 www.trsga.com


fotrhyaonurksyerovuice

I would personally like to thank you for your service and dedication to the education of the children in the great state of Georgia. You have worked hard, and although you may not be retiring under ideal circumstances, you can count on the Teachers Retirement System of Georgia (TRS) to provide you with the retirement benefits the State affords you. This retirement handbook contains the information and forms you need to apply for your TRS disability retirement benefit.
Please read through this handbook carefully and be sure to reference the Disability Retirement Checklist before submitting your forms to TRS to make sure you have completed everything necessary for us to process your retirement. Should you need additional copies of any forms contained in this handbook, you can download them from our website at www.trsga. com or you may call our office to request copies.
We are pleased to have you as a member and look forward to providing you with guidance and benefits throughout your retirement. We are here to inform you about your benefits, to ensure that your benefits are paid accurately and on time, and to update you

on new information about TRS and legislation that may impact your benefits.
You are always welcome to call or visit the TRS office if you have questions. We also attend various educational related association meetings throughout the state and would be happy to meet you and answer any questions you may have. Also, please visit our website at www.trsga.com periodically to manage or view your retirement account and receive the latest news about TRS.
Thank you again for your many years of dedication to the education of our children. We look forward to working with you and your employer to ensure that your retirement is processed both accurately and timely. At TRS, our goal is to make your retirement as easy as possible.
Sincerely,
Jeffrey L. Ezell Executive Director

Contacting the Teachers Retirement System of Georgia
The Teachers Retirement System of Georgia is proud to serve its members. Should you need to contact us for any reason, you may reach us in a variety of ways.

Website: Phone: Fax: Office:
Call Center Hours: Office Hours:

www.trsga.com (404) 352-6500 or (800) 352-0650 (404) 352-4885 Two Northside 75, Suite 100 Atlanta, GA 30318-7901 Monday - Friday, 8:00 a.m. - 5:30 p.m. EST Monday - Friday, 8:00 a.m. - 4:30 p.m. EST



disabilcihtyecrkelitsitrement
Below is a list of the forms you will need when applying for your TRS disability retirement benefit. Please review the instructions on each form prior to completion. There are forms you must complete and submit to TRS, forms your employer must complete and send to TRS, and forms your physicians must complete and send to TRS, before your retirement can be processed. Please complete (or give to the appropriate person) all forms listed below. Those forms that you complete yourself can be mailed to TRS in the self-addressed envelope included in this handbook.
Application for Disability Retirement
This form must be filled out completely and received in our office, along with the proper identification listed in the instructions, in order for TRS to process your retirement.
Physicians Report
This report must be completed and submitted to TRS by each of the physicians who have treated you for a disabling condition in the past 12 months, along with any supporting medical records. You must complete the first page and sign it prior to giving it your physician.
Member's List of Disability Information
You must complete this form and mail it with your Application for Disability Retirement. TRS staff will use this list to make sure all medical data has been received from all of your treatment sources.
Psychiatrist's/Psychologist's/Counselor's Report
If applicable, this report must be completed by your psychiatrist, psychologist, or counselor. You must complete the first page and sign it prior to giving it to the treating provider.
Hospital/Clinic Report
You must complete this form and submit it to the hospital and/or clinic where treatment was received in the past 12 months. This forms authorizes the hosptial/clinic to release your medical records to TRS for review.
Designation of Multiple Beneficiaries
Complete this form to designate more than one beneficiary to receive any funds remaining at the time of your death.
Sick Leave Certification
TRS must receive a Sick Leave Certification form from each of your employers, past and present, for verification of any unused sick leave that may be used for service credit toward your retirement. You are responsible for ensuring all employers receive and complete a copy of this form and send it to TRS. Please note: In most cases, sick leave credit will be determined after you are placed on a retirement payroll, and any benefit increase will be paid retroactively to your date of retirement.
Retirement Certification
This form must be completed by your current employer to certify your monthly salary and contributions, and your last date of employment. You are responsible for ensuring your employer receives and completes a copy of this form and sends it to TRS. The processing of your application cannot be completed without this form.
Federal and State Tax Withholding Certificates
Form W-4P Federal Withholding Certificate for Pension or Annuity Payments and Form G-4 State of Georgia Employee's Withholding Allowance Certificate allow you to designate the taxes to be withheld from your monthly benefit. You only have to complete the bottom of the W4-P and the top of the G-4 forms, and submit to TRS. Please note: The instructions on the forms ask you to detach or cut a portion of the page for submitting. We ask that you please submit the entire page of the document. This allows our staff to expedite the imaging of the documents into your records.


disabilfiatcytsrheeteitrement
If you haven't already done so, we encourage you to visit our website for the latest retirement information and to access your TRS account. To access the self-service website, go to www.trsga.com, click on the Active Member tab and then click the Account Management button. If you already have an account, you may log in and choose from a variety of menu options. If you are new to the site, you must register for an account first. Accessing your personal TRS account allows you to view your personal account information, update beneficiaries, update your mailing address, and calculate the cost to purchase service.
Important information regarding the TRS disability retirement process is highlighted below.
1. A TRS member who is mentally or physically disabled, and
who has at least 9 years service credit is eligible to apply for disability retirement. The inability to satisfactorily perform one's current work duties, due to health reasons, is the major factor in determining `disability.'
2. Disability retirement benefits are calculated using a percentage of salary formula 2% multiplied by
the total years of creditable service, times the average monthly salary for your two highest consecutive years of membership service. The resulting product is the monthly disability benefit under the maximum plan. There is no age requirement for disability retirement.
3. Applications for disability retirement should be submitted no earlier than 90 days prior to retirement
and no later than the end of the month in which your retirement is to become effective. Your retirement cannot become effective any earlier than the beginning of the month in which we receive your completed application and supporting documentation. You cannot receive a disability retirement check for any month during which you were actively employed or receiving sick leave pay.
4. Processing disability retirement applications is a lengthy process due to the time required for your
health care provider(s) to submit forms and your medical records. If multiple health care providers are involved with your situation, send our forms to them individually and simultaneously to speed completion of your medical documentation. It is your responsibility to pay for all copies of your medical records. Once all of your forms and medical records are received by TRS, your case will be referred to our medical review board for a ruling either supporting or denying your disability. The more medical data you provide, the better positioned the review board will be to understand your case and base its decision. Our review board may request an additional medical examination, which we will arrange for you at our expense. TRS will keep you apprised, in writing, on the status of your case, and will notify you when the review board renders its final decision.
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disability retirement
factsheet cont.
5. Retirement applications are processed on a New Retirement Payroll during the middle of each
month. During the processing of your application, you will receive a letter indicating the payroll date we anticipate for your first check.
6. So that we may process your application, you must have a complete retirement file at TRS. Your file
is considered complete when you have done the following: 1) purchased or declined all allowable service; 2) submitted, and TRS has received, all required disability retirement forms and supporting medical records; and 3) resolved all inconsistent reporting, if any, of your salary and contributions with your employer. If your file is completed after the effective date of your retirement, your first check will contain monthly benefits retroactive to your retirement date.
Note: The earlier you submit your application and complete your file, the more likely you are to be placed on payroll during the effective month of your retirement. Your retirement file must be complete no later than 30 days prior to your effective retirement date to be considered for payroll in the effective month of your retirement. If the processing of your retirement is delayed beyond your retirement date, it will be processed on another month's New Retirement Payroll and benefits paid will be retroactive to your effective retirement date.
7. If you need to purchase additional service to be eligible for
retirement, your retirement date will be the first of the month after you have purchased the needed service credit. If you are eligible to retire and purchase additional service credit, you must purchase the service no later than the last business day of your retirement month; however, waiting until the last business day will delay the processing of your retirement paperwork. All service must be established by the member prior to retirement. Once your retirement becomes effective, you will no longer be eligible to purchase additional service credit. Beneficiaries of deceased members cannot purchase additional service credit.
8. Your first retirement benefit payment will be mailed to you as a paper check. The next payment will
be electronically deposited into your account and you will be notified of this transfer. After this, you will not receive a monthly checkstub. You may, however, review your payment history via your personal TRS account (in the Account Management section of the website) anytime. We will send you a "change notice" whenever a change occurs to your benefit or deductions.
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disabiflaitcytsrheeteitrement
9. TRS does not administer health or dental care ben-
efits for retired members or determine eligibility to participate in a health or dental plan during retirement. TRS does not provide information regarding the filing of claims. Retiring members should direct all questions regarding health and dental insurance to their health or dental plan provider. If you decide to continue your health care coverage in retirement with Georgia's State Health Benefit Plan (SHBP), the Department of Community Health (DCH) will notify TRS of your eligibility and we will deduct the monthly premium from your benefit payment. Again, TRS does not determine eligibility for participation in the SHBP and does not provide information on the filing of claims. Specific health plan questions should be addressed to the SHBP by calling (404) 656-6322 or (800) 610-1863. Employees of the University System under the Board of Regents (BOR), will need to contact their benefits office about health and dental coverage. TRS does not deduct monthly premiums for BOR retirees. If you are already on disability and your retirement application with TRS is pending, you should contact DCH regarding your health coverage during this period.
10. While on disability retirement, you must report all employment, including self-employment to TRS,
as your disability benefit could be reduced or terminated should you become employed.


retiprleamnsent
When applying for retirement, you must designate a plan of retirement on the Application for Retirement form. Your choice will determine whether you receive the maximum benefit available to you, or if monthly benefits will be provided for your beneficiary(ies) after your death with a reduced benefit to you during your lifetime. This decision is extremely important because your plan of retirement is a permanent decision that cannot be changed after your effective date of retirement (except under very limited circumstances outlined in Georgia law). Please read each of the plan descriptions very carefully and be sure of your choice.
To obtain an estimate of your monthly lifetime benefit, please contact our office directly. TRS encourages our retiring members to direct all retirement questions, except for health and dental insurance, directly to our office. (Health insurance questions should be presented to the Department of Community Health and dental insurance questions to the Flexible Benefits Program.) To schedule an appointment or to speak with one of our Customer Service Representatives, please call (404) 352- 6500 or (800) 352-0650.
Under the provisions of Georgia law, if you die within 30 days of your effective date of retirement, you will be considered an active member at the time of your death. Your account will be settled as a death in service in accordance with the beneficiary designation(s) on file with TRS. Once your application is received by TRS, your beneficiary designation(s) will be considered valid.
Plan A - Maximum Plan
This plan provides you with the largest monthly benefit during your lifetime. Under this plan, the total of your contributions and interest at the time of your retirement will be reduced each month by your full gross monthly benefit. At your death, all monthly benefits stop. If your death occurs prior to your having been paid the total monthly benefits equal to your accumulated contributions and interest in TRS, the balance of your accumulated contributions and interest will be paid in a lump sum to the beneficiary(ies) designated on your retirement application. In most cases, your contributions and interest will be depleted within 18 months of retirement; however, your benefits will be continued throughout your life. If there is no surviving beneficiary(ies) on file at TRS at the time of your death, any applicable refund would be paid to your estate. If you select this plan, you may change your beneficiary designations at any time after retirement.
Plan B - Optional Plans (Survivorship)
At retirement, TRS offers the ability to choose from six other plans in addition to the Maximum Plan. If you select one of the survivorship plans of retirement, you can only change your retirement plan and/or designation of beneficiary(ies) after retirement if: 1) your beneficiary(ies) predeceases you; 2) your spouse is listed as beneficiary and you get divorced; or 3) you terminate your retirement, become a member again, and subsequently retire again. Only under these circumstances, as stated in Georgia law, can you change your plan of retirement and/or beneficiary(ies) designation.
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retiprleamnseconnt. t

Plan B - Option 1
Plan B Option 1 offers a lifetime monthly benefit slightly reduced from the maximum amount. Under this plan, the total of your contributions and interest at the time of your retirement will be reduced each month by only the portion of your total gross benefit made up of your contributions and interest. At your death, all monthly benefits stop. However, any remaining employee contributions and interest will be refunded to your designated beneficiary(ies) or your estate. In most cases, your contributions and interest will be depleted within 10 to 14 years after retirement, but your benefits will continue throughout your life. You may change your beneficiary designation at any time after retirement. If you have named your spouse as beneficiary and you become divorced, you may change your plan of retirement.
Survivorship Plans Under Plan B, TRS offers the following five options that allow you to provide a continuing monthly benefit to a survivor(s) after your death. If you select a survivorship plan, the amount of your monthly benefit will be reduced actuarially to allow for the monthly payment for life, both to you, and then after your death, to your designated beneficiary(ies).
The amount of the reduction in monthly benefits (cost of the option) depends on your age and the age of your beneficiary(ies). The age of the beneficiary(ies) will influence the amount of your retirement benefit under Options 2, 3, and 4. The younger the beneficiary(ies), the smaller the monthly benefit (the cost of the option is greater).

Plan B - Option 2
Plan B Option 2 offers a reduced monthly lifetime benefit based on your age and the age of your beneficiary(ies). This option guarantees that at your death, your named beneficiary(ies), if living, will receive a lifetime benefit equal to the monthly benefit you received at retirement, plus applicable increases received during your retirement prior to your death.
You may designate multiple beneficiaries to receive lifetime monthly benefits and specify the percentage of available benefits to be paid to each beneficiary. If you select two or more beneficiaries, and one predeceases you, the percentage of available benefits you selected for the remaining beneficiary(ies) will not be adjusted. Should your beneficiary(ies) predecease you, your monthly benefit will remain under Option 2 unless you are eligible to change your plan of retirement and/or beneficiary(ies) as outlined herein.

Plan B - Option 2 Pop-Up
Plan B Option 2 Pop-Up offers a reduced monthly lifetime benefit based on your age and the age of your beneficiary. If your beneficiary predeceases you, your monthly benefit will be increased to the original Maximum Plan amount plus all increases awarded to you during retirement. Under this option, you can only designate one beneficiary.

Plan B - Option 3

Plan B Option 3 offers a reduced monthly lifetime benefit based on your age and the age of your

beneficiary(ies). This benefit guarantees that at your death, your named beneficiary(ies), if living, will

receive a lifetime benefit equal to one-half of the benefit you received at retirement plus one-half of the ap-

plicable increases received during your retirement prior to your death.



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retiprleamnsecontn. t
You may also designate multiple beneficiaries under this option and specify the percentage to be paid to each beneficiary. If two or more beneficiaries are designated to receive monthly benefits, the total amount payable to all beneficiaries cannot exceed one-half of the initial monthly benefit you received at the time of retirement, plus one-half of any cost-of-living increases you received up to the date of your death. Should your beneficiary(ies) predecease you, your monthly benefit will remain under Option 3 unless you are eligible to change your plan of retirement and/or beneficiary(ies) as outlined herein.
Plan B - Option 3 Pop-Up
Plan B Option 3 Pop-Up offers a reduced monthly lifetime benefit based on your age and the age of your beneficiary. If your beneficiary predeceases you, your monthly benefit will be increased to the original Maximum Plan amount plus all increases awarded to you during retirement. Under this option, you can only designate one beneficiary.
Plan B - Option 4
Plan B Option 4 offers a reduced monthly lifetime benefit in exchange for the flexibility to designate a specific dollar amount or a specific percentage of your monthly benefit to be paid to your beneficiary(ies) after your death. The beneficiary benefits you specify under this plan cannot cause your monthly benefit to be reduced below 50% of the maximum benefit available to you. If multiple beneficiaries are designated and one or more beneficiaries predecease you, the dollar amounts or the percentages are not adjusted. Beneficiaries also receive a prorated share of any cost-of-living increases you received up to the date of death.

Plans of Retirement: a summary of advantages and disadvantages.

Reduced Benefit is

Pop-Up Retiree May Change Guaranteed Total of

Plan of Monthly for Life of Monthly Benefit Option Beneficiaries After Member's Contributions

Retirement Benefit Retiree

to Survivor Available

Retirement

& Interest

A - Maximum No

Yes

No

No

Yes

Yes

B - Option 1 Yes

Yes

No

No

Yes

Yes

B - Option 2 Yes

Yes

Yes, 100% of

Yes

No*

Yes



Retiree's Benefit

B - Option 3 Yes

Yes

Yes, 50% of

Yes

No*

Yes



Retiree's Benefit

B - Option 4 Yes

Yes

Yes, as

No

No*

Yes



Designated by



Member

* For exceptions, please refer to page 8.



types osef rcvriceeditable

To establish any service described in this section, you must have an active TRS account. To be considered an active member, you must have contributed to TRS for at least one year in the last five years. Additionally, beneficiaries of deceased members cannot establish additional service credit; it is the member's responsibility to establish all credit toward retirement. Also, all service credit must be established and paid for prior to retirement.
If you are eligible to establish any of the service types listed in this section, please contact TRS. The cost to purchase eligible service will be calculated and mailed to you.
1. Membership Service
Membership service is normal active service for which you were employed and for which you have made and are making contributions to TRS. Members who have at least nine months of service during a fiscal year (July 1 to June 30) will receive credit for one year of service. If you are employed on a 12-monthsper-year basis, you will receive credit for a year of membership service upon completion of at least nine months of service during the fiscal year ending June 30. You cannot receive credit for more than one year of service in any fiscal year. Members employed by the University System under a semester system will receive credit for one year of service if they have at least eight months of service during a fiscal year.
2. Unused Sick Leave Credit
Please refer to the Unused Sick Leave Credit section in this booklet.
3. Air Time
If you have at least 25 years of service credit established you may purchase up to three years of additional service credit. The cost to purchase the additional service credit is the full actuarial cost of the additional service. Because the cost of Air Time depends on the service you already have, TRS recommends purchasing all other types of service before purchasing Air Time. Should you decide to purchase another type of service credit after Air Time is purchased, you will be billed for any additional cost of the Air Time.

4. Out-of-State Service
After completing six years as a contributing member of TRS, you may establish one year of credit for service rendered in a public educational institution of another state. With the completion of each additional year in Georgia service, you may establish an additional year of Out-Of-State service to a maximum of ten years.
For more information about Out-of-State Service, please refer to the TRS website, www.trsga.com, in the Active Member section and/or the Member's Guide, also available on the TRS website under Publications.

5. Military Service

You can establish up to five years of retirement credit for periods of active duty military service in the armed forces of the United States. Credit can be established for qualified service during periods of national emergency (World War II, the Korean Conflict, and the Vietnam Era), for active duty military service rendered outside the periods of national emergency, for active duty from which you have been honorably discharged, for active duty rendered during any period when a military draft was in effect, and for ordered military duty such as service in "Operation Enduring Freedom."

For official dates and specific conditions that apply to each of the periods listed above, please refer to the

TRS website, www.trsga.com, in the Active Member section and/or the Member's Guide, also available on

the TRS website under Publications. 10

continued on next page

types osfercvriceedcoint.table

6. Private School Employment
You can establish up to 10 years of creditable service for previous employment in an accredited private school within the State of Georgia provided certain criteria are met. In order to establish creditable service for private school employment, you must provide satisfactory documentation to TRS that shows the period of employment and that shows the private school was accredited during that period of employment.
For more information, please refer to the TRS website, www.trsga.com, in the Active Member section and/ or the Member's Guide, also available on the TRS website under Publications.

7. PSERS Credit
If you were a member of the Public School Employees Retirement System (PSERS) and you are now a member of TRS, you may establish your PSERS service with TRS. To establish prior PSERS service, your employer must submit a completed Certification of Georgia Service form. Your cost to purchase PSERS service will be the total amount of the employee and employer contributions that would have been contributed had you been a TRS member, plus accrued interest, based on the salary you earned during your PSERS covered employment. Before PSERS service can be purchased, you must withdraw your funds from PSERS. You may not have service credit with TRS and PSERS for the same time period. For more information about PSERS credit, please refer to the TRS website, www.trsga.com, in the Active Member section.
8. Maternity Leave Credit
You can purchase credit for periods of absence from employment due to pregnancy prior to March 5, 1976. One and one-half months of credit may be awarded for each pregnancy with a maximum of six months allowable for all pregnancies. The cost to purchase this service will be the full actuarial cost.
9. Study Leave Credit
You can establish Study Leave Credit for periods of full-time graduate study if: You were a full-time teacher in the public schools of Georgia or in the University System of Georgia im-
mediately (not more than six months) prior to the period of full-time graduate study. You returned to full-time employment as a teacher in the public schools of Georgia or in the University
System of Georgia for a minimum of five years following the period of graduate study. You submit a transcript or similar document to TRS as verification of the full-time graduate study period. Any period of eligible graduate study interrupted solely for a period of active duty military service during a period in which the military draft is in effect shall be deemed not to have been interrupted provided you go immediately (not more than six months) into active duty military service.

10. State of Georgia Employment
If you were a member of the Employees' Retirement System (ERS) and withdrew your funds, you may purchase this service by paying the amount of contributions you would have contributed had you been a member of TRS, plus accrued interest. You are eligible to purchase your ERS withdrawn service after you have completed the required number of years of active TRS membership. If you have withdrawn:

11

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types osfercvriceedcoint.table
10. State of Georgia Employment (cont.)
1, 2, or 3 previous accounts, you must complete 3 years of active membership; 4 previous accounts, you must complete 5 years of active membership; 5 or more previous accounts, you must complete 10 years of active membership. If you have not withdrawn your contributions from ERS, you may transfer your service credit to TRS. Since ERS members and TRS members pay different contribution rates, in order to receive your full service credit from ERS, you must pay the difference in the amount of contributions you would have paid had you been a member of TRS, plus accrued interest. If you transfer your funds from ERS and do not pay the difference, you only will receive credit with TRS for a pro-rata portion of your ERS credit.
11. Visiting Scholar Credit
A maximum of two years of service as a visiting scholar at a public college or university may be established as creditable service if you were granted a leave of absence from a unit of the University System of Georgia for such purpose. Such service must be included in the maximum of 10 years of service allowable under the out-of-state provision of TRS law, and it cannot be established if you are eligible for benefits based on the service from another source, except social security.
12. Withdrawn Accounts If you were a member of TRS and withdrew your funds, you also withdrew your service credit for those years. After you have returned to active TRS membership, you may repay your withdrawn account(s) and reinstate the service credit you withdrew. The cost to purchase withdrawn service is the total amount of money you withdrew, plus accrued interest. You are eligible to purchase your withdrawn service after you have completed the required number of years of active TRS membership. If you have withdrawn: 1, 2, or 3 previous accounts, you must complete 3 years of active membership; 4 previous accounts, you must complete 5 years of active membership; 5 or more previous accounts, you must complete 10 years of active membership
13. Workers Compensation Disability
You may be eligible to establish retirement credit for a temporary disability caused by a job-related disease or accident. The maximum period is twelve months and must be applied for within six months of returning to service following the temporary disability. Documentation for proof of the temporary disability will be required. In most cases, the required documents will be the Employer's First Report of Injury form and the Notice of Payment or Suspension of Benefits.
Payment of Service Purchases
You may pay for eligible service purchases with a personal check, money order, or with a direct rollover from another eligible retirement plan. TRS can accept a rollover from the following plans as defined in the Internal Revenue Code: a qualified retirement plan (401(a), 403(a), or 401(k)), a tax sheltered annuity 403(b), a governmental 457 plan, or a traditional or rollover IRA. TRS cannot accept a rollover from a Roth IRA. TRS has no knowledge of your eligibility for rolling money out of your particular fund. Service can be purchased by a lump-sum payment, in one-year increments, or partial-year increments if you only worked part of a year. No partial payments or monthly installments will be accepted.
12

unusedcrseidcikt leave

Eligibility
As a member of TRS, you may establish sick leave credit at the time of retirement provided that you have a combined minimum of 60 days of unused sick leave from your current and all previous Georgia employers, and that you earned the sick leave credit while in a TRS covered position.
Limitations Unused sick leave credit is allowed for Georgia teaching service. Eligible service includes withdrawn and repurchased Georgia teaching service as well as service purchased or transferred from local retirement plans. Georgia law, however, does not permit unused sick leave credit for the following service:

ERS (Employee's Retirement System) Military Service PSERS (Public School Employees Retirement System

Maternity Leave Out-of-State Study Leave

Creditable sick leave accumulates at a maximum rate of 1-1/4 days per month. If you have worked in a system that awards more than 1-1/4 days per month, your earned total will be reduced to meet this standard. If you have worked in a system that awards fewer than 1-1/4 days per month, no adjustment will be made. If you have questions regarding your sick leave rate of accrual, please contact your employer.
Sick leave cannot be used to achieve a vested status, but it can be added to your creditable service at the time of your retirement (it can be used to complete 30 years of credit). Total creditable service cannot exceed a maximum of 40 years.
Procedure
To have your unused sick leave credited toward your retirement you must complete the member section of the Sick Leave Certification Form (available in this booklet) and forward a copy to each Georgia employer at which you have worked and contributed to TRS for verification of any unused sick leave that may be used for service credit toward retirement. Each system is responsible for completing the form and returning it to TRS, either detailing your unused sick leave or verifying its lack of records.
Calculation--When Records Do Not Exist
For the years where records are not available, TRS will use an average for the periods when the system kept accurate records and apply that average to the periods when records are not available. If an employer did not maintain accurate sick leave records, the number of unused sick days reported will be divided by the number of years for which there are records. This provides an average number of days per year that you accrued, but did not use, sick leave. This average is multiplied by the number of years for which there are no records. Since this calculation is built on an average, it cannot be finalized until after retirement, using the final number of unused sick leave days. The estimated days are added to the reported number of days to determine a final number of unused sick leave days.
Example: John worked 26 years in a position covered by TRS. The first 10 years he worked for County A, where unfortunately, records were never kept. The last 16 years, he worked in County B that kept accurate

13

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unused sick leave
credit cont.

Calculation--When Records Do Not Exist cont.
records. County B reports that over John's 16 years, he retained 100 days of sick leave. The TRS calculation to determine the first ten years of unused sick leave would be as follows:
100 days 16 years = 6.25 days/year 6.25 days/year x 10 years = 62.5 est. days 62.5 days + 100 days = 162.5 total days 162.5 days = 8 months of unused sick credit

Awarding of Credit
Unused sick leave credit is awarded on the basis of one month of service for every twenty days of sick leave. Nine months of sick leave credit are equal to one year of service irrespective of the number of months worked per year. TRS will calculate sick leave credit after receiving all Sick Leave Certification forms from your employers. Your last employer will submit its form after your last day of work. You may receive a monthly benefit prior to the application of sick leave credit to your account. In this instance, your benefit will be adjusted retroactively to your retirement date after all sick leave forms have been received by TRS and the appropriate calculations have been completed.
Sick Leave Credit Chart

Days of Unused Sick Leave
0 - 59 60 - 69 70 - 89 90 - 109 110 - 129 130 - 149 150 - 169 170 - 189 190 - 209 210 - 229 230 - 249 250 - 269 270 - 289 290 - 309 310 - 329 330 - 349 350 - 369 370 - 389 390 - 409 410 - 429 430 - 449 450 - 469
14

Creditable Service
0 months 3 months 4 months 5 months 6 months 7 months 8 months 9 months 10 months 11 months 12 months 13 months 14 months 15 months 16 months 17 months 18 months 19 months 20 months 21 months 22 months 23 months

worrektiinregmaefntter
If you retired under TRS disability retirement, you must notify your prospective employer prior to your being hired. If you work during retirement, your employer is required to report the following to TRS:
All employment. All positions covered and not covered under TRS are included (private and public sector jobs; self-employment).
All income for all jobs. As a retiree on a TRS disability retirement, you have a restriction on all income received. If income from another job(s) plus the TRS benefit is more than the current salary of the position held prior to retirement, then your TRS benefit may be reduced.
General Provisions If you work for a TRS covered employer:
You can only receive 49% of the normal full-time compensation for the position and time worked cannot exceed 49% of the normal full-time status for the position (includes classroom aides).
Gross disability benefit plus compensation for position being sought cannot exceed the current compensation for the position held at retirement.
Your employer must verify your employment prior to hiring you. If you plan to work for a private sector employer:
Gross disability benefit plus compensation for position being sought cannot exceed the current compensation for the position held at retirement.
You are responsible for reporting employment to TRS. If you retired under disability retirement, you may have your disability status reviewed at any time. You may contact the TRS office for more information regarding the laws that govern your ability to work in retirement.
Annual Audit of Employment of TRS Retirees Department of Audits will be performing detailed audits of employment records searching for TRS retirees. Any discrepancies will be investigated and, if necessary, retirement benefits may be terminated and/or funds collected for benefits wrongly paid.
15

glossary
of terms
Active Member: person employed in a TRS covered position accruing service toward retirement. Active members must contribute to TRS at least one year in the last five consecutive years.
Annuity: annual payments for life derived from the accumulated contributions of a member, the employer and earnings on those contributions.
Average Salary: the calculated average of a member's monthly salary for the highest consecutive twentyfour (24) months of membership service.
Beneficiary: upon the death of the member, person(s) designated to receive either a monthly retirement allowance or a lump-sum distribution from TRS (also see Primary and Secondary Beneficiary).
Benefit Options: the Plan of Retirement (one of seven available) selected by the member by which retirement benefits are paid to a retiree and/or beneficiary(ies).
Cost of Living Adjustment (COLA): an increase in monthly benefits tied to increases in the consumer price index (CPI), which is a statistical measurement prepared by the Bureau of Labor Statistics, a government agency, to measure changes in the price of goods and services bought by most people in the United States.
Covered Employment: positions eligible to participate in TRS. Positions include teachers, administrators, supervisors, clerks, teacher aides, secretaries, paraprofessionals, public school nurses and employees of the University System of Georgia.
Creditable Service: time accumulated by a member through covered employment with a TRS employer or other service purchased under the provisions of Georgia law.
Disability: a mental or physical impairment certified by a medical board that incapacitates the member from performance of duty in TRS covered employment.
Early Retirement: a reduced benefit payable to a member who retires prior to attaining the requirements for a full service retirement.
continued on next page
16

glossary
of terms cont.
Earnable Compensation: monies payable to a member for full, normal working time and may include monies paid to the member by an employer from grants or contracts made by outside agencies with the employer. All monies paid by an employer for a member or by a member into any plan of tax-sheltered annuity are included in earnable compensation. Earnable compensation shall not include overtime, travel allowances, or salary for a secondary position, such as night school.
Effective Date of Retirement: Not earlier than the first of the month following termination from TRS covered employment and receipt of a retirement application in the TRS office. Employee Contributions: a percentage of earnable compensation contributed by members, through an automatic payroll deduction, to TRS.
Employer: the State of Georgia, the county or independent board of education, the State Board of Education, the Board of Regents of the University System of Georgia, or any other agency of and within this state by which a teacher is paid.
Employer Contributions: a contribution made by the employer to TRS calculated using a percentage of earnable compensation to the employee. The employer contribution helps fund TRS for current and future retirement benefits and is not part of any individual member's account.
Fiscal Year: for TRS, the period beginning July 1st of one calendar year and ending June 30th of the following calendar year.
continued on next page
17

glossary
of terms cont.
Full Service Retirement: a service retirement with no early retirement penalty applied. Membership Service: time accumulated by a member through employment with a TRS employer. Partial Lump-Sum Option (PLOP): at retirement, in exchange for a permanently reduced lifetime benefit, active members can elect to receive a lump-sum distribution in addition to a monthly retirement benefit. A member's age and plan of retirement are used to determine the reduction in benefit. Pension: lifetime monthly benefit payments to retired TRS members and/or their beneficiaries. Plans of Retirement: the method selected by the member by which retirement benefits are paid to a retiree and possibly the beneficiary(ies). Pop-Up: a benefit option that includes a survivor benefit to a beneficiary. If the beneficiary predeceases the retiree, the retiree's monthly benefit reverts to the Maximum Plan. Primary Beneficiary: a person designated by a member to receive a benefit, if available, upon the death of an active member under all plans of retirement. Only the primary beneficiary(ies) can receive a mothly benefit under a survivorship plan. Retiree: the recipient of a monthly retirement benefit from TRS.
continued on next page
18

glossary
of terms cont.
Rollover: a tax deferred distribution from a qualified retirement plan [401(a), 403(a), 401(k)]; a tax sheltered annuity 403(b); a governmental 457 plan; or a traditional or rollover IRA that is transferred directly to another qualified retirement plan or IRA. TRS accepts rollovers only for purchase of creditable service.
Secondary Beneficiary: the recipient of a refund of any remaining employee contributions and interest following the death of the retiree and the primary beneficiary. A secondary beneficiary is never eligible to receive a monthly benefit under any plan of retirement.
Service Purchases: payment for additional service credit as provided in Georgia law.
Service Retirement: a monthly benefit payable to a member who has met the requirements for retirement. The requirements are attainment of age 60 with at least 10 years of service or completion of 25 years of creditable service.
Substitute Teacher: a teacher employed in a TRS covered position as a temporary replacement for another teacher. Substitute teachers are considered temporary employees and are not eligible for membership in TRS.
Survivorship Plan: a plan of retirement that will provide a continuing monthly benefit to the surviving beneficiary(ies) after the death of the retiree. Under a survivorship plan, the amount of the monthly benefit will be reduced actuarially to allow for a monthly payment for life to the retiree and then, after his or her death, a monthly benefit for life to the designated beneficiary(ies). Teacher: as defined in Georgia law, a person employed half-time or more in a TRS covered position. Halftime or more is generally defined as twenty (20) or more hours per week. Termination: the end of TRS covered employment.
Vested: the right to a retirement benefit after ten (10) years of creditable service and attainment of age 60, provided the TRS contributions have not been withdrawn.
19

Disability Retirement Forms
20

Application for Disability Retirement
If you are mentally or physically disabled (not able to satisfactorily perform your current work duties due to health reasons), and you have at least 9.5 years of creditable service, you are eligible to apply for disability retirement with the Teachers Retirement System of Georgia (TRS).

Teachers Retirement System of Georgia

To Be Completed by Member -- please print clearly

Your Information

Please print or type all personal information. Incomplete information will delay the processing of your retirement benefit.

Social Security Number

__________ ____________________________ ________________

Title (Mr, Ms etc.) Last Name

First Name

(_______)__________________ _________________________

Phone Number (daytime)

Date of Birth (mm/dd/yy)

__________ Middle Initial
___________ Sex (M or F)

_______________________________________________________________________ Street Address (home address)

Your Date of Retirement Please indicate the date you would like your retirement to be effective.
Your Retirement Plan Before you select ONE PLAN , please reference the TRS Member's Guide available at www. trsga.com under the Publications section or at the TRS office.
If you are interested in the amount of benefits you are eligible for under the various plans of retirement, please contact TRS for an estimate.
It is very important that you understand the retirement plan you are selecting, because once your first payment is deposited, you cannot change your plan of retirement except under very limited conditions.

_________________________ __________

City

State

_____________________________ Zip Code

I hereby apply for disability retirement effective on the first day of __________________
____________, 20 ____________, and elect to have my monthly retirement allowance
payable as indicated under "Your Retirement Plan."
Note: To be eligible for retirement for the date listed above, you may not work at any time during that month. Working one day during the month you plan to retire will postpone your retirement until the following month.
PLANS for monthly benefit to member and a refund only to beneficiaries (no monthly benefit to beneficiary(ies)): Plan A Plan B Option 1

PLANS for monthly benefit to member and monthly benefit only to beneficiaries. (You may have multiple beneficiaries, but no adjustment is made to the benefit if any or all beneficiaries predecease you.) Plan B Option 2 Plan B Option 3 Plan B Option 4
In accordance with my selection of Option 4, I designate a dollar amount of $ _____________ OR percentage of ___________% to be paid to the beneficiary(ies) listed in the Selection of Beneficiary sections. (Select either a dollar amount or percentage, not both.)

PLANS for monthly benefit to member and monthly benefit only to a single beneficiary. (You may have only one beneficiary and the benefit is adjusted if the beneficiary predeceases you.)
Plan B Option 2 - Pop Up

Plan B Option 3 - Pop Up

*DISABILITY*

page 1 of 4
21

Application for Disability Retirement cont.

Selection of Primary Beneficiary
If you have more than one primary beneficiary, please complete the Designation of Multiple Beneficiaries (MB-1) form.
Beneficiary(ies) designations made on this form supercede any other beneficiary(ies) designations on file with TRS.
Selection of Secondary Beneficiary A secondary beneficiary is eligible to receive a refund of remaining contributions and interest, but not a monthly benefit, upon the death of the member and primary beneficiary(ies).
If you have more than one secondary beneficiary, you will need to complete the Designation of Multiple Beneficiaries (MB-1) form.

In accordance with the retirement plan selected, I hereby designate my primary beneficiary (please check only one):
below OR on the attached Designation of Multiple Beneficiaries form (MB-1)

________________________________ Name of Beneficiary

____________________ ______________

Relationship

Sex (M or F)

________________________________ Social Security Number

____________________ Date of Birth (mm/dd/yy)

_________________________________________________________________________ Street Address (home address)

________________________________ City

____________________ _____________

State

Zip Code

In accordance with the retirement plan selected, I hereby designate my secondary beneficiary (please check only one):
below OR on the attached Designation of Multiple Beneficiaries form (MB-1)

________________________________ Name of Beneficiary

____________________ ______________

Relationship

Sex (M or F)

________________________________ Social Security Number

____________________ Date of Birth (mm/dd/yy)

_________________________________________________________________________ Street Address (home address)

________________________________

____________________ _____________

Emergency Contact Information
In an effort to protect the distribution of your retirement benefit, TRS requests that you provide an emergency contact person (someone other than your beneficiary(ies) whom you trust to handle your affairs) should all persons on file be unavailable.

________________________________ Name of Emergency Contact

____________________ _____________

Relationship

Sex (M or F)

________________________________ Social Security Number

____________________ Date of Birth (mm/dd/yy)

_________________________________________________________________________ Street Address (home address)

________________________________ City

____________________ _____________

State

Zip Code

Important Information
Applications for disability retirement cannot be accepted in the TRS office more than 90 days prior to the effective date of retirement.
Your employer(s) must complete a Retirement Certification Report for you and submit it to TRS. Your retirement application is not considered complete until these forms arrive in the TRS office.
Upon receipt of your application for disability retirement and all of your medical information, we will provide you written notification of the status of our progress in processing your application.
The more medical data you provide, the more information the TRS Medical Board will have on which to base their decision. If there is insufficient information about the disabling impairment(s), we will arrange for a special examination or test with an appropriate treatment source to gather the necessary information. Any such examination will be at the expense of TRS and every effort will be made to schedule this appointment with a provider as close as possible to your area of residence.
page 2 of 4
22

Application for Disability Retirement cont.

Payment Method
With the exception of your first monthly check, which will be mailed to your home address, your subsequent monthly checks will be electronically sent to your financial institution. Please check only one option.
Please be sure to tape your voided check or deposit slip in the box on the right.
TRS will send your financial institution a notification (prenote) that will alert them that your retirement pay will arrive electronically in the following month.

Your monthly benefit checks are automatically deposited into your banking account via Electronic Funds Transfer (EFT). I wish to deposit my benefit checks into my CHECKING account. My VOIDED CHECK
is attached below. I wish to deposit my benefit checks into my SAVINGS account. My VOIDED DEPOSIT
SLIP is attached below.
(Please use transparent tape across top edge of check or deposit ticket. Do not staple or glue.)
To have funds deposited to your:
Checking Account: Please tape a VOIDED CHECK inside this box.
Savings Account: Please tape a VOIDED savings account DEPOSIT SLIP inside this box.

Your net retirement benefit will be deposited into your account on the first business day of each month. A change in your account number will require your benefit to be mailed to your home address until the first business day of the month following the issuance of another prenote to your financial institution.

On the first business day of the month when your EFT services are scheduled to start, you should verify that your financial institution received your deposit. If your deposit has not been made by the second business day of the month, call TRS immediately. Please notify TRS immediately if your financial institution changes your account number and/or routing number.

You will receive notice from TRS only when there is a change in your monthly net benefit. Should any change occur, TRS will send you a notice of the change(s) and the new amount deposited to your account.

Your Initials
Please read this information and initial next to each heading that you understand and comply with the following TRS regulations.

TIP

If you have questions

about any of the

statements listed,

please contact TRS by

calling (404) 352-6500

or (800) 352-0650.

Required Disability Forms: In addition to this form, I understand that the following forms must be completed and submitted before my application can be considered: Member's List of Disability Information that you must complete; Physician's Report that your physician(s) must complete; Psychiatrist's, Psychologist's, Counselor's Report that your treatment provider must complete (if applicable); and Hospital/ Clinic Report that must be completed by the hospital/clinic from which you received treatment.
Payment Method: With the exception of my first monthly check, which will be mailed to my home address, I understand that my subsequent monthly benefit checks will be electronically sent to my financial institution.
Required Identification Documents: In accordance with the requirements for retirement application, I have attached photocopies of personal identification containing the date of birth for myself and my beneficiary(ies). Acceptable forms of ID are: driver's license, passport, certified birth certificate, immigration papers, or a state ID issued in lieu of a driver's license. My application will not be processed without this identification.
continued on the next page
page 3 of 4
23

Application for Disability Retirement cont.

Your Initials cont. Please read this information and initial next to each heading that you understand and comply with the following TRS regulations.
Your Signature Please sign and date verifying the information provided on all four pages of this application is accurate.

Service Credit for Retirement: I understand that it is my responsibility to purchase all available service credit PRIOR to the effective date of my retirement. It is my responsibility to contact TRS to purchase this service credit. Should I not purchase such service prior to the effective date of my retirement, I understand that I MAY NOT purchase additional service after my retirement date is effective (no exceptions allowed).
Changing Retirement Plans: Once my monthly benefit payment has been deposited, I cannot change my plan of retirement except under the limited conditions specifically stated in Georgia law.
Changing Beneficiaries: I understand that if I have selected Plan A or Plan B - Option 1, I may change my designation of beneficiary(ies) at any time prior to my death. If I have selected Plan B - Option 2 or 2 Pop Up, Option 3 or 3 Pop Up, or Option 4, I cannot change my beneficiary(ies) except under the limited conditions specifically stated in Georgia law.
Active Membership: I understand that should my death occur within 30 days of my effective retirement date, I will be considered an active member at the time of my death in accordance with Georgia law. My account will be settled as a death in service in accordance with the active member beneficiary designation(s) I have selected on this retirement application.
Re-activating Membership: I understand that should I return to work in a position covered by TRS, I must notify TRS immediately.
Taxes: As required by federal regulations, TRS will withhold federal taxes, based on married and 3 allowances, from the taxable portion of your monthly benefits unless you complete and submit to TRS a federal form W-4P where you may indicate not to have withholding apply or to have withholding apply at a different rate. Georgia law also considers your benefits taxable but does not require withholding. I understand that I may elect to have Georgia taxes withheld by completing Georgia tax form G-4 and submitting it to TRS. Failure to withhold may result in tax penalties.

By signing below,
I verify that the information provided on all four pages of this Application for Disability Retirement is accurate;
I acknowledge that I have read and understand the plans of retirement and the provisions for optional allowances available to me. Once my first benefit payment has been deposited, I cannot change my plan of retirement except under the limited conditions stated in Georgia law;
I understand that the beneficiary designation(s) I have listed on this application supercede any other beneficiary designation(s) on file with TRS. Once this application is received by either TRS or my school system, my beneficiary designation(s) is considered valid; and
I understand that all required medical forms must be completed and received by TRS in order for the TRS Medical Board to consider my Application for Disability.

___________________________________________ Signature

______________________ Date

page 4 of 4
24

Physician's Report

Teachers Retirement System of Georgia

This form must be filled out if you are applying for Disability Retirement.

As a member of the Teachers Retirement System of Georgia (TRS), it is your responsibility to obtain the necessary medical information from all treating sources needed to determine the status of your disability retirement request. Any charges for this information will be at your expense. In some cases, TRS may require an evaluation by an independent physician of our choice. If this is necessary, you will be notified and TRS will assume the responsibility for that cost only.

You need to send one of these reports to each physican from whom you have received treatment/diagnosis for your disabling condition in the last 12 months. Please attach a copy of your current job description to each report. Job descriptions are available from your personnel department.

TRS guarantees the confidentiality of the information provided on this form.

To Be Completed by Member -- please print clearly



_______________________________________

Socia l Secu rity Number

Date of Birth





_________________________________________

__________________________________

______________

Last Name

First Name

Middle Initial

__________________________________________________________________________________________________________ Street Address or P.O. Box

(_________)___________________ Telephone Number (daytime)

___________________________ City

__________ State

_____________________ Zip Code

_____________________________________________________

(_________)________________________________

Name of Physician

Physician's Phone Number



_________________________________________________________________________________________________________

Address of Physician

__________________________________________________ City

__________ State

___________________________________ Zip Code

Authorization for Release of Medical Information
This is my written authorization to release to the Teachers Retirement System of Georgia any and all medical records and information for the purpose of processing my disability retirement application. This includes any psychiatric/psychological records.

____________________________________________________ Signature

___________________________________ Date

After completing this section, please forward this report to your physican. If you have been treated/diagnosed by more than one physician in the last 12 months, you must send a copy of this report to each one. Do not forget to attach a copy of your job description to each report

To Be Completed by Physican -- please print clearly
Please document diseases, diagnoses and current condition(s). Please include copies of test results, notes from office visits, blood tests, and x-ray reports for the past 12 months. Be sure to include any records that prove the medical diagnosis.
This person has applied for disability retirement with the Teachers Retirement System of Georgia and you have been named as a treating physician. Your information is vital in determining disability status for the job currently held. A job description is attached for your review. TRS needs a current evaluation. Please state specifically whether or not you determine that this person is disabled for the current job held. The person has signed above authorizing the release of all medical information.
Please bill the person named above for any charges relating to this request. Thank you for your cooperation.

Ability to Perform Job
For the currently held position, and according to the job description attached, I find that this person is:

*MEDICAL* Able to perform the job as described.
25

Yes

No

page 1 of 2

Physician's Report cont.

To Be Completed by Physician -- please print clearly

Job Duties
Please state the job duties that the person cannot perform.

____________________________________________________________________________________________ ____________________________________________________________________________________________

Disability Diagnosis

____________________________________________________________________________________________

Please state the diagnosis for the

cause of the disability.

____________________________________________________________________________________________

Physical Findings & Test Results
Please state the specific physical findings and test results confirming this diagnosis.

____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Please send copies of these test results. If cancer is involved, attach copies of the confirming pathology reports. If AIDS is involved, attach copies of HIV and CD4 test reports. If you do not have copies of these reports, please tell us where they can be obtained.

Abnormalities
Please state the specific abnormalities disabling this patient.

____________________________________________________________________________________________ ____________________________________________________________________________________________

Recovery
Using the attached job description, can this patient be expected to recover sufficiently to return to the described job?

Yes

No If yes, please state an approximate time.

____________________________________________________________________________________________

____________________________________________________________________________________________

Treatment
Please state the treatment you have recommended.
Has the patient followed through with the recommended treatment?
State dates and results of treatment.

____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________

Referrals
If you have referred this patient to any specialists, please list them.

____________________________________________________________________________________________

Name

Specialty

Address

Date of Referral

____________________________________________________________________________________________

Name

Specialty

Address

Date of Referral

____________________________________________________________________________________________

Name

Specialty

Address

Date of Referral

Other Information
Please provide any other information that you think will assist in the determination of this patient's claim for disability. If more space is needed, please explain on a separate page and attach to this report.

____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________

Physician's Authorization
By signing, you certify that the information provided above is accurate.
Confidentiality will be maintained.

________________________________________ Signature of Physician
________________________________________ Patient's Last Name, First Name

____________________________________________ Physician's Name Printed
____________________________________________ Date

After completing this report, please forward it, along with any attachments, directly to TRS. We appreciate your assistance. page 2 of 2
26

Member's List of Disability Information

Teachers Retirement System of Georgia

This form must be filled out if you are applying for Disability Retirement.

Please provide TRS with the physicians (including specialists), psychologists, psychiatrists, hospitals and/or clinics you have seen in the last 12 months from whom you are requesting medical information relating to your disability.

Be sure to provide complete information for each provider. Please send this form with your Application for Disability Retirement form to TRS. If you need additional space, please use the back of this page.

To Be Completed by Member -- please print clearly



________________________________________

Social Se curity Nu mber

Date of Birth





______________________________________________

__________________________________

_______________

Last Name

First Name

Middle Initial

______________________________________________________________________________________________________________________ Street Address or P.O. Box

(_________)___________________ Telephone Number (daytime)

_________________________________ City

__________ State

_______________________ Zip Code

________________________________________________________________ Name of Provider

(_________)_____________________________ Phone Number

_____________________________________________________________________________________________________________________ Address (street, city, state, zip code)

___________________ _____________________ _______________________________________________________________________

Date Last Seen

Date of Next Appointment Reason for Treatment

________________________________________________________________ Name of Provider

(_________)_____________________________ Phone Number

_____________________________________________________________________________________________________________________ Address (street, city, state, zip code)

___________________ _____________________ _______________________________________________________________________

Date Last Seen

Date of Next Appointment Reason for Treatment

________________________________________________________________ Name of Provider

(_________)_____________________________ Phone Number

_____________________________________________________________________________________________________________________ Address (street, city, state, zip code)

___________________ _____________________ _______________________________________________________________________

Date Last Seen

Date of Next Appointment Reason for Treatment

________________________________________________________________ Name of Provider

(_________)_____________________________ Phone Number

_____________________________________________________________________________________________________________________ Address (street, city, state, zip code)

___________________ _____________________ _______________________________________________________________________

Date Last Seen

Date of Next Appointment Reason for Treatment

________________________________________________________________ Name of Provider

(_________)_____________________________ Phone Number

_____________________________________________________________________________________________________________________ Address (street, city, state, zip code)

___________________ Date Last Seen

_____________________ Date of Next Appointment

_______________________________________________________________________

Reason for Treatment

*MEDICAL*

27

Back of Member's List of Disability Information form. Leave blank. Back of Member's List of Disability Information form. Leave blank. Back of Member's List of Disability Information form. Leave blank. Back of Member's List of Disability Information form. Leave blank. Back of Member's List of Disability Information form. Leave blank. Back of Member's List of Disability Information form. Leave blank. Back of Member's List of Disability Information form. Leave blank. Back of Member's List of Disability Information form. Leave blank. Back of Member's List of Disability Information form. Leave blank. Back of Member's List of Disability Information form. Leave blank. Back of Member's List of Disability Information form. Leave blank. Back of Member's List of Disability Information form. Leave blank. Back of Member's List of Disability Information form. Leave blank. Back of Member's List of Disability Information form. Leave blank. Back of Member's List of Disability Information form. Leave blank. Back of Member's List of Disability Information form. Leave blank. Back of Member's List of Disability Information form. Leave blank. Back of Member's List of Disability Information form. Leave blank. Back of Member's List of Disability Information form. Leave blank. Back of Member's List of Disability Information form. Leave blank. Back of Member's List of Disability Information form. Leave blank. Back of Member's List of Disability Information form. Leave blank. Back of Member's List of Disability Information form. Leave blank. Back of Member's List of Disability Information form. Leave blank. Back of Member's List of Disability Information form. Leave blank. Back of Member's List of Disability Information form. Leave blank. Back of Member's List of Disability Information form. Leave blank. Back of Member's List of Disability Information form. Leave blank. Back of Member's List of Disability Information form. Leave blank. Back of Member's List of Disability Information form. Leave blank. Back of Member's List of Disability Information form. Leave blank.
28

Psychiatrist's, Psychologist's or Counselor's Report

Teachers Retirement System of Georgia

This form pertains to those members applying for Disability Retirement.

As a member of the Teachers Retirement System of Georgia (TRS), it is your responsibility to obtain the necessary medical information from all treating sources needed to determine the status of your disability retirement request. Any charges for this information will be at your expense. In some cases, TRS may require an evaluation by an independent treatment provider of our choice. If this is necessary, you will be notified and TRS will assume the responsibility for that cost only.
You need to send one of these reports to each psychiatrist, psychologist or counselor from whom you have received treatment/diagnosis for your disabling condition in the last 12 months. Please attach a copy of your current job description to each report. Job descriptions are available from your personnel department.
TRS guarantees the confidentiality of the information provided on this form.

To Be Completed by Member -- please print clearly



______________________________

Social Se curity Nu mber

Date of Birth



______________________________________________

_________________________________________

________________

Last Name

First Name

Middle Initial

_______________________________________________________________________________________________________________________ Street Address or P.O. Box

(_________)___________________ Telephone Number (daytime)

_______________________________ City

__________ State

________________________ Zip Code

_____________________________________________________________ Name of Treating Source

(_________)______________________________________ Phone Number of Treating Source

_______________________________________________________________________________________________________________________ Address of Treating Source

__________________________________________________ City

__________ State

________________________________________ Zip Code

Authorization for Release of Medical Information
This is my written authorization to release to the Teachers Retirement System of Georgia any and all medical records and information for the purpose of processing my disability retirement application. This includes any psychiatric/psychological records.

____________________________________________________ Signature

________________________________________ Date

After completing this section, please forward this report to your psychiatrist, psychologist or counselor. If you have been treated/diagnosed by more than one in the last 12 months, you must send a copy of this report to each one. Do not forget to attach a copy of your job description to each report

To Be Completed by Treating Source -- please print clearly
Please complete all 4 pages of this form.
This person has applied for disability retirement with the Teachers Retirement System of Georgia and you have been named as a treatment provider. Your information is vital in determining disability status for the job currently held. A job description is attached for your review. TRS needs a current evaluation. Please state specifically whether or not you determine that this person is disabled for the current job held. The person has signed above authorizing the release of all medical information.
Please bill the person named above for any charges relating to this request. Thank you for your cooperation.

Ability to Perform Job
For the currently held position, and according to the job description attached, I find that this person is:

*MEDICAL*

Able to perform the job as described.

Yes

No

29

page 1 of 4

Psychiatrist's, Psychologist's or Counselor's Report cont.

To Be Completed by Treating Source -- please print clearly

_________________________________________ Patient's Last Name

____________________________ First Name

______________________ Social Security Number

Job Duties
Please state the job duties that the person cannot perform.

____________________________________________________________________________________________ ____________________________________________________________________________________________

Present Illness
Please describe:
1. The patient's mental condition
2. Age at onset
3. Diagnosis
4. Symptoms supporting diagnosis (include any history of substance abuse or violent behavior)
5. Treatment (past, present, medication, response, compliance and side effects-include photocopies of progress notes and hospital discharge summaries if available)

1.__________________________________________________________________________________________ ____________________________________________________________________________________________ 2.__________________________________________________________________________________________ 3.__________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 4.__________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 5.__________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________

Past History
Please list the significant physical/mental factors in patient's background (serious historical illness or disability of patient or family members)

____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________

Daily Activities
Please include examples and information on how independently the patient acts, however long he/she is able to sustain activities, and the quality and appropriateness of the activities.

1. Describe a typical day (yard work, house work, cooking, TV, visiting, etc.) ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 2. Interests (hobbies, sports, social and church activities, etc.) ____________________________________________________________________________________________ ____________________________________________________________________________________________ 3. Ability to relate to others (frequency of trips outside the home, freqency and quality of interactions with friends, family, neighbors, crowds, etc.) ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 4. Personal habits (appearance, grooming habits, personal hygiene, clothing, etc.) ____________________________________________________________________________________________ ____________________________________________________________________________________________ 5. Current ability to function in a work setting (ability to concentrate, pay attention, sustain pace, understand and remember directions, and adapt to changes) ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________
page 2 of 4
30

Psychiatrist's, Psychologist's or Counselor's Report cont.

To Be Completed by Treating Source -- please print clearly

_________________________________________ Patient's Last Name

____________________________ First Name

______________________ Social Security Number

Current Mental Status
Please describe the following by using illustrative incidents when possible.

1. Behavior and interaction with therapists (appropriate, hostile, suspicious, aggressive, evasive, passive, dramatic, etc.) ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 2. Psychomotor behavior (agitation, retardation, tics, tension, tremors, etc.) ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 3. Speech (slow, loud, pressured, understandable, impaired in any way) ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 4. Mood/Affect/Facial Expression (quantity, appropriateness, type, range of feelings expressed, lability, eye contact, etc.) ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 5. Sensorium/Perceptual abnormalities (disoriented, delusional, hallucinations, etc.) ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 6. Flow of thought (loose associations, coherent, rambling, perseverative, etc.) ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 7. Content of thought (illogical, apprehensive, obsessive, suicidal, etc.) ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________

page 3 of 4
31

Psychiatrist's, Psychologist's or Counselor's Report cont.

To Be Completed by Treating Source -- please print clearly

_________________________________________ Patient's Last Name

____________________________ ______________________

First Name

Social Security Number

Current Mental Status cont.
Please describe the following by using illustrative incidents when possible.

8. Memory (remote, recent, immediate) ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 9. Attention and consciousness (impaired in any way by illness, injury, drugs, etc.) ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 10. Estimated intelligence and ability to concentrate/focus ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 11. Reliability of patient's report ____________________________________________________________________________________________ ____________________________________________________________________________________________ 12. Physical condition (include unrealistic beliefs about personal illness or complaints of chronic pain) ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 13. Specific symptoms (low energy level, insomnia, guilt, poor appetite and weight loss, anhedonia, autonomic hyperactivity, vigilance and scanning, phobias, intrusive and traumatic recollections, substance abuse, etc.) ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________

Other Information
Please provide any other information that you think will assist in the determination of this patient's claim for disability.

____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________

Physician's Authorization
By signing, you certify that the information provided above is accurate.
Confidentiality will be maintained.

________________________________________

Signature of Physician



___________________________ ___________

Physician's Name Printed

Date

________________________________________ Signature of MH Professional ___________________________ ___________ MH Professional's Name Printed Date

After completing this report, please forward it, along with any attachments, directly to TRS. We appreciate your assistance. page 4 of 4
32

Hospital/Clinic Report

Teachers Retirement System of Georgia

This form must be filled out if you are applying for Disability Retirement.

As a member of the Teachers Retirement System of Georgia (TRS), it is your responsibility to obtain the medical information necessary to determine the status of your disability retirement request. Any charges for this information will be at your expense. If you have any questions, please call TRS.

You need to send one of these reports to each hospital and/or clinic where you received treatment and/or diagnosis in the last 12 months.

TRS guarantees the confidentiality of the information provided on this form.

To Be Completed by Member -- please print clearly



_______________________________________

Social S ecurity N umber

Date of Birth





_________________________________________

__________________________________

______________

Last Name

First Name

Middle Initial

__________________________________________________________________________________________________________ Street Address or P.O. Box

(_________)___________________ Telephone Number (daytime)

___________________________ City

__________ State

_____________________ Zip Code

___________________________________________________________ Date(s) of Treatment or Diagnosis

____________________________________ Date(s) of Discharge

_____________________________________________________

(_________)_________________________

Name of Institution

Institution Phone Number



__________________________________________________________________________________________________________

Address of Institution

__________________________________________________ City

__________ State

____________________________________ Zip Code

Authorization for Release of Medical Information
This is my written authorization to release to the Teachers Retirement System of Georgia any and all medical records and information for the purpose of processing my disability retirement application. This includes any psychiatric/psychological records.

____________________________________________________ Signature

____________________________________ Date

After completing this section, please forward this report to your hospital/clinic. If you have been treated/diagnosed at more than one hospital/ clinic in the last 12 months, you must send a copy of this report to each one.

Instructions to Hospital/Clinic

1. Please send all information requested below that pertains to this patient:

Patient History Notes Physical Notes Operative Notes Radiology Reports Lab Reports

Pathology Reports Diagnostic Studies Discharge Summary for the Dates of Treatment the patient listed above Surgeon's Report Surgery Records

2. Please include any records regarding treatment or diagnosis for the past 12 months.

3. Please send the requested information directly to TRS at the address listed below. The information you provide is vital in the determination of disability status for this patient.

4. Please bill the person named above for any charges relating to this request. Confidentiality will be maintained. Thank you for your cooperation.

*MEDICAL*
33

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34

Designation of Multiple Beneficiaries

To Be Completed by Member -- please print clearly

Your Information
Print or type all personal information below.

S ocial S ecurity Numb er



___________________________________

_______________________

Last Name

First Name

____________ Middle Initial

Beneficiary Designation Please designate your primary and/or secondary beneficiaries. The total percentage for primary beneficiaries should equal 100%. The total percentage for secondary beneficiaries should equal 100%. For example, if you have 3 primary beneficiaries, you need to make sure that the percentages allotted equal 100% (e.g., 40%, 30%, 30%).
*mb-1*
Your Signature Please sign and date verifying the information provided above is accurate.

PRIMARY BENEFICIARIES

1. _______________________________ _______________ __________

Name of Beneficiary

Date of Birth

Sex (M or F)

_______________ Relationship to Me

____________________________________ Address

______________ _______

City

State

_____________ Zip Code

Soc. Sec. No. _______________________ Percentage of available benefits to be paid ________%

2. _______________________________ _______________ __________

Name of Beneficiary

Date of Birth

Sex (M or F)

_______________ Relationship to Me

____________________________________ Address

______________ _______

City

State

_____________ Zip Code

Soc. Sec. No. _______________________ Percentage of available benefits to be paid ________%

3. _______________________________ _______________ __________

Name of Beneficiary

Date of Birth

Sex (M or F)

_______________ Relationship to Me

____________________________________ Address

______________ _______

City

State

_____________ Zip Code

Soc. Sec. No. _______________________ Percentage of available benefits to be paid ________%

4. _______________________________ _______________ __________

Name of Beneficiary

Date of Birth

Sex (M or F)

_______________ Relationship to Me

____________________________________ Address

______________ _______

City

State

_____________ Zip Code

Soc. Sec. No. _______________________ Percentage of available benefits to be paid ________%

5. _______________________________ _______________ __________

Name of Beneficiary

Date of Birth

Sex (M or F)

_______________ Relationship to Me

____________________________________ Address

______________ _______

City

State

_____________ Zip Code

Soc. Sec. No. _______________________ Percentage of available benefits to be paid ________%

SECONDARY BENEFICIARIES

1. _______________________________ _______________ __________

Name of Beneficiary

Date of Birth

Sex (M or F)

_______________ Relationship to Me

____________________________________ Address

______________ _______

City

State

_____________ Zip Code

Soc. Sec. No. ______________________ Percentage of available benefits to be paid _________%

2. _______________________________ _______________ __________

Name of Beneficiary

Date of Birth

Sex (M or F)

_______________ Relationship to Me

____________________________________ Address

______________ _______

City

State

_____________ Zip Code

Soc. Sec. No. ______________________ Percentage of available benefits to be paid _________%

3. _______________________________ _______________ __________

Name of Beneficiary

Date of Birth

Sex (M or F)

_______________ Relationship to Me

____________________________________ Address

______________ _______

City

State

_____________ Zip Code

Soc. Sec. No. ______________________ Percentage of available benefits to be paid _________%

__________________________________________________ Signature
35

__________________ Date

Back of Designation of Multiple Beneficiaries form. Leave blank. Back of Designation of Multiple Beneficiaries form. Leave blank. Back of Designation of Multiple Beneficiaries form. Leave blank. Back of Designation of Multiple Beneficiaries form. Leave blank. Back of Designation of Multiple Beneficiaries form. Leave blank. Back of Designation of Multiple Beneficiaries form. Leave blank. Back of Designation of Multiple Beneficiaries form. Leave blank. Back of Designation of Multiple Beneficiaries form. Leave blank. Back of Designation of Multiple Beneficiaries form. Leave blank. Back of Designation of Multiple Beneficiaries form. Leave blank. Back of Designation of Multiple Beneficiaries form. Leave blank. Back of Designation of Multiple Beneficiaries form. Leave blank. Back of Designation of Multiple Beneficiaries form. Leave blank. Back of Designation of Multiple Beneficiaries form. Leave blank. Back of Designation of Multiple Beneficiaries form. Leave blank. Back of Designation of Multiple Beneficiaries form. Leave blank. Back of Designation of Multiple Beneficiaries form. Leave blank. Back of Designation of Multiple Beneficiaries form. Leave blank. Back of Designation of Multiple Beneficiaries form. Leave blank. Back of Designation of Multiple Beneficiaries form. Leave blank. Back of Designation of Multiple Beneficiaries form. Leave blank. Back of Designation of Multiple Beneficiaries form. Leave blank. Back of Designation of Multiple Beneficiaries form. Leave blank. Back of Designation of Multiple Beneficiaries form. Leave blank. Back of Designation of Multiple Beneficiaries form. Leave blank. Back of Designation of Multiple Beneficiaries form. Leave blank. Back of Designation of Multiple Beneficiaries form. Leave blank. Back of Designation of Multiple Beneficiaries form. Leave blank. Back of Designation of Multiple Beneficiaries form. Leave blank.
36

Sick Leave Certification-Final
To Be Completed by Member -- please print clearly

Your Information
Print or type all personal information. When listing your name, please include all names under which you may have been employed.



S ocial Secur ity Num ber



___________________________________ Last Name

_______________________ First Name

____________ Middle Initial

(_______)__________________________ Telephone Number (home)

(_______)________________________________ Telephone Number (work)

_________________________________________________________________________________

Street Address (home address)



_______________________________ City

_____________ State

__________________________ Zipcode

Employment Information
Your date of retirement cannot be earlier than the 1st of the month following your last date of employment.

_________________________________________ Anticipated Last Date of Employment

______________________ _________________

Current Employer

Start Date/End Date

______________________ _________________

Previous Employer

Start Date/End Date

__________________________________ Anticipated Date of Retirement

_____________________ ________________

Previous Employer

Start Date/End Date

_____________________ ________________

Previous Employer

Start Date/End Date

Sick Leave Credit

1. I do not wish to pursue sick leave credit. I understand I cannot establish sick leave credit at a

#2--if you do not wish to

later date.

receive credit for only a portion of your service time, list the

2. I do not wish to submit sick leave verification for the following employer ___________________

employer's name and period

________________________________________________________________ for the following

of time you do not want to

date(s)______________________________. I understand I cannot establish sick leave credit at

include.

a later date.

Your Signature
Please sign and date verifying the information provided above is accurate.

__________________________________________________ Signature

__________________ Date

To Be Completed by Employer -- please print clearly
Sick Leave Status
Please verify the information on this form is the member's final sick leave status by checking this box.

Sick Leave Verification
1. Please verify the Final Balance of Sick Leave subject to the qualifications listed on the back of this form. The number of sick days should be the balance prior to any lump sum payment at retirement. If applicable, list dates of missing records.

1. Our personnel/payroll records show a final sick leave balance for this member of _______________ days for the dates of ___________________ to ___________________.
2. The total listed above reflects sick leave accrued at 1 1/4 days or less per month of service, OR The total listed above reflects sick leave accrued at a rate higher than 1 1/4 days per month of service. Sick leave was awarded at _________________ days per month of service. Please attach an explanation of accrual rate(s).
3. We do not have sick leave records for the dates of________________________________ to ____________________________.

Sick Leave Lump-Sum Payments

The employee elected to receive ____________ days of unused sick leave in a lump-sum payment upon termination; AND/OR the employee received ____________ days of unused sick leave in a lumpsum payment as an attendance incentive or for any other program. Describe program on back of form.

Your Signature
Please sign and date verifying the information provided above is accurate.

I certify that this information conforms to the personnel/payroll records of this system for this individual and the requirements outlined in the legislation and the TRS procedures for determining the amount of accumulated sick leave to be used for retirement purposes. I further certify that the above information is complete from all existing records for this person in this system.

_________________________________________ Approving Authority's Signature

_______________________ Title

*sickleave* _________________________________________ System Name

_______________________

Date

page 1 of 2

37

Sick Leave Certification-Final cont.
EMPLOYERS: The accumulated sick leave that a TRS member may use for retirement credit may or may not be the final total showing on the employee's last pay stub or in your records. Policies such as forfeited leave, a leave bank, annual payments of leave, and other situations in your system may require you to recalculate the final balance for the determination of allowable retirement credit. The dates you list don't have to cover the entire employment time if records are not available. The following considerations should be observed when entering the Final Balance of Sick Leave on this form. The Final Balance of Sick Leave should: reflect the days earned based on the policies of your system for this individual employee. not exceed 1 1/4 days per month of service. If your policies call for days awarded in excess of 1 1/4 days per month of service, you
may recalculate the total based on the limit of 1 1/4 days, or you may indicate your basis for accumulation on the form in the area provided. include all days forfeited due to your policy limitation of accrued leave. include all days to be paid in a lump-sum payment at retirement. not include the days for which the employee was paid when absent. reflect the reduction for any sick leave days used for personal leave. not include the days for which the employee was paid in a lump sum at the end of each year. reflect the reduction for any sick leave days donated to a sick leave bank and used from a sick leave bank which exceed the days donated. (For example, if an employee donates 2 days to a sick leave bank and uses 5 days sick leave from the bank, then the 2 days donated should be deducted from the Final Balance of Sick Leave.) not include days granted by special action of your governing body. not include days transferred from another system. However, if you do include any transferred days, you must indicate in the section below the number of transferred days included in the total and the system from which the days were transferred.
Number of sick days transferred included in total _______________________________________________________________
System from which the sick days were transferred ______________________________________________________________
This form must be submitted AFTER the employee has terminated. Since the employee could use sick leave just prior to his or her retirement date and, as a result, receive less sick leave credit, TRS will not adjust a member's benefit for sick leave credit until after the member has terminated.
You must also report ALL lump-sum payments to the member on the the front side of this form, which includes any attendance incentive pay that is paid out to the member at termination. Failure to report any lump-sum payments related to sick leave will result in reduced sick leave credit and a reduced retirement benefit to the member. If applicable, please describe the conditions of your attendance-incentive pay program or other program: __________________________________________________________________________________________________________ __________________________________________________________________________________________________________
MEMBERS: After you have filled out your portion of the form, you will need to make a copy of it for each employer you listed on the reverse and send the copy to them for your sick leave verification. Your sick leave credit cannot be calculated until forms from all employers are received at TRS. It is up to you to follow up with your employers to make sure they have submitted the form to TRS. Your retirement will be processed without your sick leave credit. Your credit will be calculated after you are on retirement payroll with TRS and your monthly benefit will be adjusted retroactively to your date of retirement.
*Under O.C.G.A Section 45-11-1, the falsification of state records by any public officer or other person is a felony subject to a fine and imprisonment. **The law requires you to keep the sick leave records for your past, present and future TRS covered employees for a period of 50 years.
page 2 of 2
38

Retirement Certification Report

To Be Completed by Retiring Member's Employer -- please print clearly

Member Information
If this is the first TRS-8 for the member, please mark the "estimated" box on the right. If you are submitting changes to a TRS-8 already sent to TRS, mark the "corrected" box. Also, please indicate the retiring member's data. The position and contract dates should be the ones in force for the final year of employment.

Estimated

Corrected

Social Security Number

_____________________________________ Last Name

________________________ First Name

__________ Middle Initial

_____________________________________________________________________________________ Title or Position

_____________________________________________________________________________________ Contract Dates

Contract Type & Pay Method
If the member has had changes in position and/or his or her contract during the last three years (semester changes NOT included), please attach an explanation.

1. Contract Type (please check one)

9 or 10 month

Semester

11 month

12 month

Other ______________

2. Payment Method (please check one)

12 Equal Monthly Payments

10 Equal Monthly Payments

9 Equal Monthly Payments

9 Equal Monthly Payments and 1 Month Summer pay

Biweekly Other ________________

Note: In the event you need to check more than one contract type or payment method, please attach an explanation of the changes during the year.

Explanation of Salary & Contributions
This section should include, as accurately as possible, all information for the member's last year of employment including that which has already been reported, and any future salary and contributions. Please read instructions on the back for more details.

Month/
Year
07/_______ 08/_______ 09/_______ 10/_______ 11/_______ 12/_______ 01/_______ 02/_______ 03/_______ 04/_______ 05/_______ 06/_______ 07/_______ 08/_______

Total
Salary
____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________

Total
Contributions
______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________

Regular
Contributions
______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________

Pro-rata
Summer Pay
______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________

Summer
School
___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________

Paid
Leave
___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________

Other
___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________

Explanation of OTHER contributions listed above:______________________________________________________________________ ___________________________________________________________________________________________________________

1. Colleges and Universities: please list semester dates
Fall ___________________________ Winter ________________________ Spring _________________________ Maymester _____________________ Summer _______________________

2. All Other School Systems: please list regular and summer school year dates
Regular School Year _________________________ Summer School _____________________________
3. Health Insurance: indicate the month the last health insurance deduction is to be made Last Month of Deduction ______________________

4. Termination Dates: indicate the last date that the member will be at work, the last day of the contract and the last month of contributions you will be submitting.
Last Day at Work _________________________
Last Day in Contract ______________________
Last Month of Contributions_________________

Signature of Approving Authority
Please sign and date verifying the information provided above is correct and submit form to TRS.
*TRS-8*

I certify that the above named individual has left or will leave the service of this public school system or educational institution as indicated and that the information reported on this form conforms to the payroll records of this system for this individual. I also agree that if any changes to the information occur, I will submit a corrected Retirement Certification Form immediately.

__________________________________________________ Approving Authority's Signature

______________________________ Title

__________________________________________________ System Name
39

______________________________

Date

page 1 of 2

Retirement Certification Report cont.
Explanation of Salary & Contributions Instructions
TOTAL SALARY should include only those salaries from which TRS contributions should be made. Salary subject to TRS contributions includes:
regular contract salary (half-time or more employment) summer employment pay all pro-rata summer pay (including less than half-time employment) salary adjustments if part of the regular contract sick leave paid on a daily basis prior to retirement with a termination date at the conclusion of the payment of the sick leave Not Included: annual or vacation leave at the end of employment (terminal annual leave), retirement incentive payments, or lump
sum payments for sick leave If you have any questions regarding allowable salary subject to TRS contributions, please visit the TRS website or contact your assigned TRS representative in the Employer Services Division. TOTAL CONTRIBUTIONS withheld or to be withheld should be listed in this column. If the total contributions withheld for a particular month include a composite of contributions, please list the breakdown of the contributions in the proper column. If you show contributions in the "Other" column, please explain in the place provided. If more space is needed, please attach an explanation to this form before submitting to TRS. HEALTH INSURANCE: When indicating the month from which the last health insurance deduction should be made, it should be the last month in which salary is paid. For example: if the last month of salary is paid in March and a health insurance premium is deducted, you would indicate March as the last deduction, even though the premium will cover the member's health insurance for April. TERMINATION DATES: An eligible member's retirement cannot be effective until the first of the month following his/her last date of employment. If his/her last date of employment is April 30, do not show May 1 on this form. This will cause the effective date of the retirement to be June 1. If the last month of contributions are after the termination date and they are not already explained in the spaces provided, please attach an explanation on a separate sheet of paper. (examples include: last pay due to system's payroll schedule, bi-weekly employee, etc.)
Fluctuations in Salary and Contributions
If the member has had any unusual fluctuations in the salary and contributions during the last three years that you have not already explained, please attach an explanation on another sheet.
page 2 of 2
40

Tax Forms
41

intafoxrmfoartmion
When filling out the G-4P State of Georgia Employee's Withholding Allowance Certificate, please read below before completing the form.
Items 1 - 6: located at the top of the form must be completed.
Item 3: please interpret subsection B, "both spouses working," to mean that both you and your spouse are actually receiving an income. This would include your TRS retirement benefit, as well as any retirement pension that your spouse is receiving. Subsequently, please interpret subsection C, "one spouse working", as only one of the two of you are receiving an income.
Please ensure that you sign and date the form in the appropriate spaces located directly under item 7 on the front page.
Please do not cut the form as stated on the form. We ask that you please submit the entire page of the document. This allows our staff to expedite the imaging of the documents into your records.
Page 2: In the event you need to have an additional amount withheld above the amount to be deducted based on the tax tables, please use Schedule A on page 2 of this form to determine the appropriate additional withholding allowances and/or amount. Additional allowances should be entered in Item 5 on page 1 of this form. Additional withholdings should be entered in the designated space at the bottom of Schedule A where a signature is also required. Please be advised that you are able to specify a fixed amount of taxes to be withheld. If you choose to do this, you will need to mark through the word "additional" at the bottom of Schedule A and insert the word "Total" before the word "Withholding." A signature is required at the end of that section in order for your request to be processed.
If you encounter any difficulty in completing this or the federal W-4P forms, please contact your accountant, the State of Georgia Department of Revenue, or the Internal Revenue Service for assistance.
42

Form G-4 (Rev. 10/06) 1a. YOUR FULL NAME

STATE OF GEORGIA
EMPLOYEE'S WITHHOLDING ALLOWANCE CERTIFICATE
1b. YOUR SOCIAL SECURITY NUMBER

2a. HOME ADDRESS (Number, Street, or Rural Route)

2b. CITY, STATE AND ZIP CODE

READ INSTRUCTIONS ON REVERSE SIDE BEFORE COMPLETING THIS FORM 3. MARITAL STATUS (If you do not wish to claim an allowance, enter "0" in the brackets beside your marital status.)

A. Single: enter 0 or 1 ................................... [ ]

4. DEPENDENT ALLOWANCES [ ]

B. Married Filing Joint, both ........................... spouses working: enter 0 or 1 or 2 ............ [ ]

C. Married Filing Joint, one ............................ spouse working: enter 0 or 1 or 2 .............. [ ]

5. ADDITIONAL ALLOWANCES [ ] (complete worksheet below)

D. Married Filing Separate: enter 0 or 1 or 2 ........................................ [ ]

E. Head of Household: .................................. enter 0 or 1 or 2 ........................................ [ ]

6. ADDITIONAL WITHHOLDING $

WORKSHEET FOR CALCULATING ADDITIONAL ALLOWANCES This worksheet must be completed if Line 5 is greater than zero.

1. COMPLETE THIS LINE ONLY IF USING STANDARD DEDUCTION:

Yourself: Age 65 or over

Blind

Spouse: Age 65 or over

Blind

Number of boxes checked

x 1300 = $

2. ADDITIONAL ALLOWANCES FOR DEDUCTIONS:

A. Estimated Federal Itemized Deductions ................................................................ $

B. Georgia Standard Deduction (enter one): Single/Head of Household $2,300

Each Spouse

$1,500 $

C. Subtract Line B from Line A ................................................................................................... $

D. Allowable Deductions to Federal Adjusted Gross Income ...................................................... $

E. Add the Amounts on Lines 1, 2C, and 2D .............................................................................. $

F. Estimate of Taxable Income not Subject to Withholding......................................................... $

G. Subtract Line F from Line E (if zero or less, stop here) .......................................................... $

H. Divide the Amount on Line G by $3,000. Enter total here and on Line 5 above ......................

This is the maximum number of additional allowances you can claim. If the remainder is over $1,500 round up.

7. LETTER USED (Marital Status A, B, C, D, or E )

TOTAL ALLOWANCES (Total of Lines 3 - 5)

(Employer: The letter indicates the tax tables in the Employer's Tax Guide)

8. EXEMPT: Skip this line if you entered information on Lines 3 - 7. Read the instructions for Line 8 on page 2.
I claim exemption from withholding because I incurred no Georgia income tax liability last year and I do not expect to have a Georgia income tax liability this year. Check here

I certify under penalty of perjury that I am entitled to the number of withholding allowances or the exemption from withholding status claimed on this Form G-4. Also, I authorize my employer to deduct per pay period the additional amount listed above.

Employee's Signature

Date

Employer: Complete Line 9 and mail entire form only if the employee claims over 14 allowances or exempt from withholding.

If necessary, mail form to: Georgia Department of Revenue, Withholding Tax Unit, P. O. Box 49432, Atlanta, GA 30359.

9. EMPLOYER'S NAME AND ADDRESS:

EMPLOYER'S FEIN:

EMPLOYER'S WH#:

Do not accept forms claiming additional allowances unless the worksheet has been completed. Do not accept forms claiming exempt if numbers are written on Lines 3 - 7.
43

INSTRUCTIONS FOR COMPLETING FORM G-4

Enter your full name, address and social security number in boxes 1a through 2b.

Line 3: Write the number of allowances you are claiming in the brackets beside your marital status.

A. Single - enter 1 if you are claiming yourself

B. Married Filing Joint, both spouses working - enter 1 if you claim yourself or 2 if you claim yourself and your spouse

C. Married Filing Joint, one spouse working - enter 1 if you claim yourself or 2 if you claim yourself and your spouse

D. Married Filing Separate - enter 1 if you claim yourself or 2 if you claim yourself and your spouse

E. Head of Household - enter 1 if you claim yourself but the individual(s) for whom you maintain a home does not qualify as a dependent; or 2 if you claim yourself and a qualified dependent for whom you maintain a home Do not claim a deduction on Line 4 for a dependent used to qualify you as head of household

Line 4: Enter the number of dependent allowances you are entitled to claim.

Line 5: Complete the worksheet on Form G-4 if you claim additional allowances. Enter the number from Line H here. Failure to complete and submit the worksheet will result in automatic denial of your claim.

Line 6: Enter a specific dollar amount that you authorize your employer to withhold in addition to the tax withheld based on your marital status and number of allowances.

Line 7: Enter the letter of your marital status from Line 3. Enter total of the numbers on Lines 3 - 5.

Line 8:

Check the box if you qualify to claim exempt from withholding. You can claim exempt if you filed a Georgia income tax return last year and the amount on Line 4 of Form 500EZ or Line 16 of Form 500 was zero, and you expect to file a Georgia tax return this year and will not have a tax liability. You can not claim exempt if you did not file a Georgia income tax return for the previous tax year. Receiving a refund for the previous tax year does not qualify you to claim exempt. Do not complete Lines 3 - 7 if claiming exempt.

EXAMPLES: Your employer withheld $500 of Georgia income tax from your wages. The amount on Line 4 of Form 500EZ or Line 16 of Form 500 was $100. Your tax liability is the amount on Line 4 or Line 16; therefore, you do not qualify to claim exempt.

Your employer withheld $500 of Georgia income tax from your wages. The amount on Line 4 of Form 500EZ or Line 16 of Form 500 was $0 (zero) and you filed a prior year income tax return. Your tax liability is the amount on Line 4 or Line 16; therefore, you qualify to claim exempt.

NOTE: Effective January 1, 2003, the deduction allowed for the dependents increased from $2,700 to $3,000. This does not apply to the deduction allowed for you or your spouse.
O.C.G.A. 48-7-102 requires you to complete and submit Form G-4 to your employer in order to have tax withheld from your wages. By correctly completing this form, you can adjust the amount of tax withheld to meet your tax liability. Failure to submit a properly completed Form G-4 will result in your employer withholding tax as though you are single with zero allowances.

Employers are required to mail any Form G-4 claiming more than 14 allowances or exempt from withholding to the Georgia Department of Revenue for approval. Employers will honor the properly completed form as submitted pending notification from the Withholding Tax Unit. Upon approval, such forms remain in effect until changed or until February 15 of the following year. Employers who know that a G-4 is erroneous should not honor the form and should withhold as if the employee is single claiming zero allowances until a corrected form has been received.

44

Form W-4P
Department of the Treasury Internal Revenue Service

Withholding Certificate for Pension or Annuity Payments

OMB No. 1545-0074
07

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 payments to U.S. citizens 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 3 and 4. Your previously filed Form W-4P will remain in effect if you do not file a Form W-4P for 2007.
What do I need to do? Complete lines A through G of the Personal Allowances Worksheet. Use the additional worksheets on page 2 to adjust your withholding allowances for itemized deductions, adjustments to income, certain credits, or multiple pensions/more-than-one-income situations. If you do not want any federal income tax withheld (see Purpose above), 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.

Personal Allowances Worksheet (Keep for your records.)

A Enter "1" for yourself if no one else can claim you as a dependent

A

B Enter "1" if:

You are single and have only one pension; or You are married, have only one pension, and your spouse has no income subject to withholding; or Your income from a second pension or a job, or your

B

spouse's pension or wages (or the total of all) is $1,000 or less.

C Enter "1" for your spouse. But, you may choose to enter "-0-" if you are married and have either a spouse who

has income subject to withholding or you have more than one source of income subject to withholding. (Entering

"-0-" may help you avoid having too little tax withheld.)

C

D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return

D

E Enter "1" if you will file as head of household on your tax return

E

F Child Tax Credit (including additional child tax credit):

If your total income will be less than $57,000 ($85,000 if married), enter "2" for each eligible child.

If your total income will be between $57,000 and $84,000 ($85,000 and $119,000 if married), enter "1" for each

eligible child plus "1" additional if you have 4 or more eligible children

F

G Add lines A through F and enter total here. (Note. This may be different from the number of exemptions you claim

on your tax return.)

G

For
accuracy, complete all worksheets

If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions and Adjustments Worksheet on page 2.
If you have more than one source of income subject to withholding or a spouse with income subject to withholding and your combined income from all sources exceeds $40,000 ($25,000 if married), see the Multiple Pensions/More-Than-One-Income Worksheet on page 2 to avoid having too little tax withheld.

that apply. If neither of the above situations applies, stop here and enter the number from line G on line 2

of Form W-4P below.

Cut here and give Form W-4P to the payer of your pension or annuity. Keep the top part for your records.

Form W-4P
Department of the Treasury Internal Revenue Service

Withholding Certificate for Pension or Annuity Payments
For Privacy Act and Paperwork Reduction Act Notice, see page 4.

Type or print your first name and middle initial. Last name

OMB No. 1545-0074
07
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. (Do not complete lines 2 or 3.)

2 Total number of allowances and marital status you are claiming for withholding from each periodic pension or

annuity payment. (You may also designate an additional dollar amount on line 3.)



Marital status: Single

Married

Married, but withhold at higher "Single" rate

(Enter number of allowances.)

3 Additional amount, if any, you want withheld from each pension or annuity payment. (Note. For periodic payments,

you cannot enter an amount here without entering the number (including zero) of allowances on line 2.)

$

Your signature

Cat. No. 10225T
45

Date

Form W-4P (2007)

Form W-4P (2007)

Deductions and Adjustments Worksheet

Page 2

Note. Use this worksheet only if you plan to itemize deductions, claim certain credits, or claim adjustments to income on your 2007 tax return.

1 Enter an estimate of your 2007 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state and local taxes, medical expenses in excess of 7.5% of your income, and miscellaneous deductions. (For 2007, you may have to reduce your itemized deductions if your income

is over $156,400 ($78,200 if married filing separately). See Worksheet 2 in Pub. 919 for details.)

1$

2 Enter:

$10,700 if married filing jointly or qualifying widow(er) $ 7,850 if head of household



2$

$ 5,350 if single or married filing separately

3 Subtract line 2 from line 1. If zero or less, enter "-0-"

3$

4 Enter an estimate of your 2007 adjustments to income, including alimony, deductible IRA contributions,

and student loan interest

4$

5 Add lines 3 and 4 and enter the total. (Include any credit amounts from Worksheet 8 in Pub. 919.)

5$

6 Enter an estimate of your 2007 income not subject to withholding (such as dividends or interest)

6$

7 Subtract line 6 from line 5. If zero or less, enter "-0-"

7$

8 Divide the amount on line 7 by $3,400 and enter the result here. Drop any fraction

8

9 Enter the number from the Personal Allowances Worksheet, line G, page 1

9

10 Add lines 8 and 9 and enter the total here. If you 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. Complete only if the instructions under line G, page 1, direct you here. This applies if you (and your spouse if married filing a joint return) 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 line G, page 1 (or from line 10 above if you used theDeductions and Adjustments

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 are married filing jointly and the amount from the highest paying pension or job is

$50,000 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 49 below to calculate 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 pay periods remaining in 2007. For example, divide by 12 if you are paid

every month and you complete this form in December 2006. 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

Table 2

Married Filing Jointly

All Others

Married Filing Jointly

All Others

If wages from LOWEST paying pension or job are--
$0 - $4,500 4,501 - 9,000 9,001 - 18,000 18,001 - 22,000 22,001 - 26,000 26,001 - 32,000 32,001 - 38,000 38,001 - 46,000 46,001 - 55,000 55,001 - 60,000 60,001 - 65,000 65,001 - 75,000 75,001 - 95,000 95,001 - 105,000 105,001 - 120,000 120,001 and over

Enter on line 2 above
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

If wages from LOWEST paying pension or job are--
$0 - $6,000 6,001 - 12,000 12,001 - 19,000 19,001 - 26,000 26,001 - 35,000 35,001 - 50,000 50,001 - 65,000 65,001 - 80,000 80,001 - 90,000 90,001 - 120,000 120,001 and over

Enter on line 2 above
0 1 2 3 4 5 6 7 8 9 10

If wages from HIGHEST

Enter on

If wages from HIGHEST

paying pension or job are-- line 7 above paying pension or job are--

$0 - $65,000 65,001 - 120,000 120,001 - 170,000 170,001 - 300,000 300,001 and over

$510 850 950
1,120 1,190

$0 - $35,000 35,001 - 80,000 80,001 - 150,000 150,001 - 340,000 340,001 and over

Enter on line 7 above
$510 850 950
1,120 1,190

46

Form W-4P (2007)
Additional Instructions
Section references are to the Internal Revenue Code.
When should I complete the form? Complete Form W-4P and give it to the payer as soon as possible. Get Pub. 919, How Do I Adjust My Tax Withholding, to see how the dollar amount you are having withheld compares to your projected total federal income tax for 2007. You may also use the Withholding Calculator on the IRS website at www.irs.gov/individuals for help in determining how many withholding allowances to claim on your Form W-4P.
Multiple pensions/more than one income. To figure the number of allowances that you may claim, combine allowances and income subject to withholding from all sources on one worksheet. You may file a Form W-4P with each pension payer, but do not claim the same allowances more than once. Your withholding will usually be more accurate if you claim all allowances on the Form W-4P for the highest source of income subject to withholding.
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. Call 1-800-TAX-FORM (1-800-829-3676) to get Form 1040-ES and Pub. 505, Tax Withholding and Estimated Tax. You can also get forms and publications from the IRS website at www.irs.gov.
If you have income from wages, see Pub. 919 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 Annuities
Generally, 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 depends on (a) the kind of payment you receive, (b) whether the payments are 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 4 for special withholding rules that apply to payments outside the United States and payments to foreign persons.
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 on page 4.

Page 3
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. Under current law, you cannot designate a specific dollar amount to be withheld. However, you can designate an additional amount to be withheld on line 3.
If you do not 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 Outside the United States on page 4.
Caution. If you do not submit Form W-4P to your payer, the payer must withhold on periodic payments as if you are married claiming three withholding allowances. Generally, this means that tax will be withheld if your pension or annuity is at least $1,520 a month.
If you submit a Form W-4P that does not contain your correct taxpayer identification number (TIN), the payer must withhold as if you are single claiming zero withholding allowances even if you choose not to have federal income tax withheld.
There are some kinds of periodic payments for which you cannot use Form W-4P because they are 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 deferred compensation plans of exempt organizations 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 nonperiodic payments (but see Eligible rollover distribution--20% withholding on page 4) 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 TIN) to your payer and checking the box on line 1. Generally, your choice not to have federal income tax withheld will apply to any later payment from the same plan. You cannot 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 does not contain your correct TIN, the payer cannot honor your request not to have income tax withheld and must withhold 10% of the payment for federal income tax.

47

Form W-4P (2007)
Eligible rollover distribution--20% withholding. Distributions you receive from qualified pension or annuity plans (for example, 401(k) pension plans, IRAs, and section 457(b) plans maintained by a governmental employer) or tax-sheltered annuities that are eligible to be rolled over tax free to an IRA or qualified plan are subject to a flat 20% federal withholding rate. The 20% withholding rate is required, and you cannot choose not to have income tax withheld from eligible rollover distributions. Do not give Form W-4P to your payer unless you want an additional amount withheld. Then, complete line 3 of Form W-4P and submit the form to your payer.
Note. The payer will not withhold federal income tax if the entire distribution is transferred by the plan administrator in a direct rollover to a traditional IRA, qualified pension plan, governmental section 457(b) plan (if allowed by the plan), or tax-sheltered annuity.
Distributions that are (a) required by law, (b) one of a specified series of equal payments, or (c) qualifying "hardship" distributions are not "eligible rollover distributions" and are not subject to the mandatory 20% federal income tax withholding. See Pub. 505 for details. See also Nonperiodic payments--10% withholding on page 3.
Changing Your "No Withholding" Choice
Periodic 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 rate set by law (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 Outside the United States
Unless you are a nonresident alien, withholding (in the manner described above) is required on any periodic or nonperiodic payments that are delivered to you outside the United States or its possessions. You cannot 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, to the payer before receiving any payments. The Form W-8BEN must contain the foreign person's TIN.

Page 4
Statement of Federal Income Tax Withheld From Your Pension or Annuity
By January 31 of next year, your payer will furnish a statement to you on Form 1099-R, Distributions From Pensions, Annuities, Retirement or Profit-Sharing Plans, IRAs, 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 are 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.
Privacy Act and Paperwork Reduction Act Notice
We ask for the information on this form to carry out the Internal Revenue laws of the United States. You are 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 are 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).
Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation, and to cities, states, and the District of Columbia 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 are 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.

48

Two Northside 75, Suite 100 Atlanta, Georgia 30318 (404) 352-6500 (800) 352-0650 www.trsga.com