CLAIMANT S STATEMENT INSTRUCTIONS PLEASE READ CAREFULLY This form must be completed and filed in order to claim death benefits due as a result of a TRS member s death, or the death of a beneficiary participant in TRS Tax-Deferred Annuity (TDA) Program. Please file this form in a timely manner to preserve certain rights to distribution options. TRS must also receive the following before any payments can be made: A certified or original death certificate. A photocopy of government-issued photo identification and a photocopy of the claimant s Social Security card or documentation of a Tax Information Number (TIN) obtained from the Internal Revenue Service (IRS). All claimants must complete Part A, sign their names in Part E, and have this form notarized in Part F. If the death benefit is a lump-sum payment, the claimant must also complete Part D. If the claimant is a minor, his/her legal guardian must complete Parts A, B, and C and enclose proof of legal guardianship. If the claim is filed by a designated beneficiary, or by a trustee named in either a testamentary or an inter vivos trust, Part B must be completed. If the claim is filed by an executor, administrator, or other legal representative (not a designated beneficiary), Part C must be completed. A certificate of appointment, duly authenticated, must be attached to this form. Do NOT file this form if: You are an eligible TDA beneficiary and you elect to use the total amount of a TDA death benefit to establish a TRS TDA Program account. Instead, you should file a TDA Enrollment Form for Beneficiaries (code TD80) for your TDA death benefit. (However, if you are also due a death benefit under the Qualified Pension Plan (QPP), you must file a Claimant s Statement (code DB17) in order to claim your QPP death benefit.) A death benefit is payable to the estate of a deceased TRS member, and the estate is not probated. Instead, the claimant may file a Claimant s Affidavit for Benefit under Section 1310 (code DB14). DB17 (8/17) CONTINUED ON PAGE 2 PAGE 1
CONTINUED FROM PAGE 1 GENERAL PROVISIONS In accordance with TRS policy, applicable interest will stop accruing on any death benefit due as of the date the benefit is paid or six months after the date of the initial TRS letter accompanying your claim forms, whichever is earlier. (For more information on how interest is determined, please visit our website and search for death benefit interest.) According to IRS rules, a Direct Rollover is not allowed on any portion of a death benefit that represents a Required Minimum Distribution (RMD), or on any amount that would not otherwise be eligible for a rollover. In addition, any partial lump-sum payment made directly to you may not be less than any RMD due you. Spouse and non-spouse beneficiaries who are eligible to annuitize their death benefit must file a Claimant s Statement and a Beneficiary s Election Form for Method of Payment (code DB12) by October 31 of the year following the year of the member s death (except for beneficiaries of deceased Tier II members, who have 90 days from the date of the member s death). Otherwise, they may lose this right. Spouse and non-spouse beneficiaries who roll over their death benefit to an Inherited Individual Retirement Arrangement (IRA) may be eligible to receive their required distributions over their life expectancy. In order to qualify, these beneficiaries must file a Claimant s Statement and the applicable Direct Rollover form by October 31 of the year following the year of the member s death. Otherwise, if the rollover occurs after this deadline, they must fully withdraw these funds from the Inherited IRA by the end of the fifth calendar year following the year of the TRS member s death. TA CONSEQUENCES Death benefits are generally federally taxable and may be subject to state and local taxes for the year in which the benefit is distributed. The IRS requires that TRS withhold tax from death benefits as indicated below: 20% of the taxable portion of any lump-sum death benefit that is eligible for rollover, but is paid directly to a spouse beneficiary. 10% of a fractional payment or any lump-sum death benefit paid directly to a non-spouse beneficiary, executor, or administrator, even if this amount is not otherwise taxable. (However, the claimant may elect to have a percentage other than 10% withheld in Part D of this form.) 30% of a payment made to a beneficiary who is not required to file U.S. income taxes due to foreign citizenship (unless the claimant s country has a different tax withholding arrangement with the U.S.) Withheld amounts will be sent to the IRS as credit toward the claimant s federal taxes for the year of distribution. DB17 (8/17) CONTINUED ON PAGE 3 PAGE 2
CLAIMANT S STATEMENT Please read the instructions on page 1 before completing this form. (NOTE: Please print in black or blue ink, and initial any changes that you make on this form.) PART A: The claimant must provide the below information about the deceased TRS member. First Name MI Last Name Social Security Number (last 4 digits only) Date of Birth (MM/DD/YYYY) Date of Death (MM/DD/YYYY) TRS Membership/Retirement/TDAB No. Is the estate of the above deceased TRS member being administered by a third-party legal representative (i.e., an individual other than the claimant)? Yes No If yes above, the claimant must provide the below information about the legal representative. First Name MI Last Name Relationship to Deceased Permanent Home Address Apt. No. Primary Phone Number (Check one: Home Work Mobile) City State Zip Code Alternate Phone Number (Check one: Home Work Mobile) Country Estate Identification Number PART B: If the claimant is the designated beneficiary, or a trustee named in either a testamentary or an inter vivos trust, (s)he must provide the below information. If the claimant is a minor, the designated legal guardian must provide the minor s information. (Note: TRS will update an address on file based on the information you provide below, so do not enter a temporary address. To register any changes to your permanent address (and/or phone number), please file a Beneficiary s Change of Address Form (code DM14) with TRS.) Claimant s First Name MI Last Name Claimant s Social Security Number Permanent Home Address Apt. No. Claimant s Date of Birth (MM/DD/YYYY) City State Zip Code Relationship to Deceased Country Primary Phone Number (Check one: Home Work Mobile) Alternate Phone Number (Check one: Home Work Mobile) DB17 (8/17) CONTINUED ON PAGE 4 PAGE 3
CONTINUED FROM PAGE 3 PART C: If the claimant is not a beneficiary or trustee, (s)he must provide the below information. (Note: TRS will update an address on file based on the information you provide below, so do not enter a temporary address. To register any changes to your permanent address (and/or phone number), please file a Beneficiary s Change of Address Form (code DM14) with TRS.) In what capacity is this claim filed (e.g., executor, administrator, guardian)? Claimant s First Name MI Last Name Claimant s Social Security Number Permanent Home Address Apt. No. Claimant s Date of Birth (MM/DD/YYYY) City State Zip Code Relationship to Deceased Country Primary Phone Number (Check one: Home Work Mobile) Estate Identification Number Alternate Phone Number (Check one: Home Work Mobile) PART D: If the death benefit is a lump-sum payment, the claimant must complete Part D below. QPP LUMP-SUM DEATH BENEFIT If you are receiving a lump-sum QPP death benefit, elect ONE of the following choices. Please read the Tax Consequences on page 2 before making your election. If you do not elect a choice below, your payment would be delayed. I am a spouse beneficiary and want to directly receive my entire QPP lump-sum death benefit. I am a spouse beneficiary and want TRS to directly roll over part or all of the taxable portion of my QPP lump-sum death benefit to one or more eligible IRAs or Section 401 Plan(s). Therefore, I have enclosed a QPP Direct Rollover Election Form for Withdrawal/Distribution of Lump-Sum Disability Benefit/Death Benefit (code DB32) with this form. I am a spouse beneficiary and want TRS to directly roll over part or all of the taxable portion of my QPP lump-sum death benefit to an Inherited IRA(s). Therefore, I have enclosed a QPP Direct Rollover Application for Lump-Sum Benefit to an Inherited IRA (For Spouse Beneficiaries Only) (code DB32b) with this form. I am a non-spouse beneficiary and want to directly receive my entire QPP lump-sum death benefit. If applicable, check this box and indicate a withholding percentage other than 10% that you would like applied to this lump-sum QPP death benefit: %. I am a non-spouse beneficiary and want TRS to directly roll over part or all of the taxable portion of my QPP lump-sum death benefit to an Inherited IRA. Therefore, I have enclosed a QPP Direct Rollover Application for Lump-Sum QPP Death Benefit to an Inherited IRA (For Non-Spouse Beneficiaries Only) (code DB32c) with this form. If applicable, check this box and indicate a withholding percentage other than 10% that you would like applied to this lump-sum QPP death benefit: %. I am an executor, administrator, or legal guardian and want to receive the entire QPP lump-sum death benefit on behalf of an estate or minor. If applicable, check this box and indicate a withholding percentage other than 10% that you would like applied to this lump-sum QPP death benefit: %. DB17 (8/17) CONTINUED ON PAGE 5 PAGE 4
CONTINUED FROM PAGE 4 PART D (continued): TDA LUMP-SUM DEATH BENEFIT If you are receiving a lump-sum TDA death benefit, elect ONE of the following choices. Please read the Tax Consequences on page 2 before making your election. If you do not elect a choice below, your payment would be delayed. I am a spouse beneficiary and want to directly receive my entire TDA lump-sum death benefit. I am a spouse beneficiary and want TRS to directly roll over part or all of the taxable portion of my TDA lump-sum death benefit to one or more eligible IRAs or Section 401 Plan(s). Therefore, I have enclosed a TDA Direct Rollover Election Form for Lump-Sum TDA Death Benefit (For Spouse Beneficiaries Only) (code DB34a) with this form. I am a spouse beneficiary and want TRS to directly roll over part or all of the taxable portion of my TDA lump-sum death benefit to an Inherited IRA(s). Therefore, I have enclosed a TDA Direct Rollover Application for Lump-Sum TDA Death Benefit to an Inherited IRA (For Spouse Beneficiaries Only) (code DB34d) with this form. I am a non-spouse beneficiary and want to directly receive my entire TDA lump-sum death benefit. If applicable, check this box and indicate a withholding percentage other than 10% that you would like applied to this lump-sum TDA death benefit: %. I am a non-spouse beneficiary and want TRS to directly roll over part or all of the taxable portion of my TDA lump-sum death benefit to an Inherited IRA(s). Therefore, I have enclosed a TDA Direct Rollover Application for Lump-Sum TDA Death Benefit to an Inherited IRA (For Non-Spouse Beneficiaries Only) (code DB34c) with this form. If applicable, check this box and indicate a withholding percentage other than 10% that you would like applied to this lump-sum TDA death benefit: %. I am an executor, administrator, or legal guardian and want to receive the entire TDA lump-sum death benefit on behalf of an estate or minor. If applicable, check this box and indicate a withholding percentage other than 10% that you would like applied to this lump-sum TDA death benefit: %. DB17 (8/17) CONTINUED ON PAGE 6 PAGE 5
CONTINUED FROM PAGE 5 PART E: The claimant (or minor s legal guardian) must read the following statement and sign and date this form in the presence of a notary. I agree, as to all times herein and in the future, without regard to any statutes of limitations, to indemnify and hold harmless TRS and the Teachers Retirement Board, from any and all liability or loss incurred by reason of the payment of this benefit. I further agree to assist TRS and the Teachers Retirement Board in their defense of any actions which may be brought against TRS and the Board as a result of the delivery of these funds. CLAIMANT S SIGNATURE DATE (MM/DD/YYYY) PART F: TO BE COMPLETED BY A NOTARY (NOTE: Attestation made outside the U.S. must be executed before an American consul.) State of ) ) s.s.: County of ) On the day of,, before me personally appeared the person known to me to be, the individual who executed the foregoing instrument and acknowledged to me that (s)he executed the same. Signature: Official Title: Expiration Date of Commission: DB17 (8/17) PAGE 6