May Be A

A copy of your Social Security card is required to be attached in order to process your refund. You may be contacted by LASERS to verify information provided on this form.

Please read the "Special Tax Notice Regarding Plan Payments" which explains important tax information, options and effects of this transaction. Forms submitted prior to the member's termination date will not be accepted. I hereby make application for a refund of my accumulated contributions. I certify that I have left all state employment and that I am no longer eligible to be a member of LASERS. I also certify that I am not transferring from one state agency to another, or from one division to another within the same agency. I also understand that a refund cannot be issued until the retirement contributions on my behalf have been submitted by my employing agency, and I have remained out of state service for at least 30 days. Depending upon my retirement plan, I understand if I were to leave my contributions with LASERS, I would be eligible to receive a pension benefit with five or more years of service credit at age 60 or 62; or 10 or more years of service credit at age 60. I also understand that my contributions may be paid to me in one or more payments. I understand that most refunds are issued approximately 90 days from the date all necessary documents are received by LASERS. I hereby waive and relinquish for myself, my heirs, and my assigns, all accrued rights to the System. I understand that all rights and creditable service are forfeited by acceptance of said refund and that I will not be eligible for any benefit. I further understand that in order to reestablish the forfeited creditable service, I must be employed in state service, be a contributing member of the System for at least 18 months, and then repay the refund plus interest as established by law. I understand that if I refund my contributions and return to work in a LASERS eligible position, I will be considered a newly hired employee under the provisions in effect at that time. Failure to complete the proper sections below will stop the refund process.

SECTION 1: INSTRUCTIONS

PRINT ALL INFORMATION

www.lasersonline.org

Refund of Accumulated Contributions

(La. R.S. 11:537)

P.O. Box 44213, Baton Rouge, LA 70804-4213

225-***-**** · Toll-Free 1-800-***-****

Fax 225-***-****

Form 2-01

R052024

Member's First Name Middle Name Last Name Today's Date Member's Mailing Address City State Zip Code

Home Area Code/Phone Number Mobile Area Code/Phone Number Email Address Member's Birth Date 2-01 R052024 CONTINUE ON NEXT PAGE ER2 Page 1 of 2 Please select ONE of the following two options:

Initials

Initials

Option 1: Contributions to be refunded to member

I elect to receive a refund of my contributions and understand that 20% federal income taxes will be withheld on the taxable portion of my refund (unless I submit the attached IRS Form W4-R along with this request to have more than 20% withheld) and that tax information will be supplied to the IRS. I understand that my refund payment will be direct deposited into the account listed in Section 3 on this form. All members choosing Option 1 must complete Section 3 to have funds paid through an electronic transfer. Any person may seek an exception to the payment method by completing Form 4-06, Application for Waiver of Electronic Funds Transfer Request, in the presence of a Notary Public. Option 2: Rollover of sheltered contributions

I elect to make a qualified direct rollover to the financial institution indicated in Section 5 below. A representative of the financial institution or eligible employer plan must sign and complete Section 5 below. I understand that any unsheltered contributions will be refunded directly to me, sent to the address listed on this form. If rolling over to a Roth IRA, according to IRS Publication 590-A, I understand that I will be subject to the ordinary tax withholding of 20%. LASERS will not withhold the 20%. I will be responsible for the taxes when I file my tax return. I understand that LASERS recommends that I consult with my tax advisor if I have any questions. SECTION 2: SELECTION OF DISTRIBUTION OPTION

Social Security Number

Yes No

Would you like your address, phone number(s), and email address changed to the above? 2-01 R052024 RETAIN A COPY FOR YOUR RECORDS ER2 Page 2 of 2 Social Security Number

Financial Institution Name

Check Payee Receiving Account Number

State Zip Code

Financial Institution Authorized Signature Date

Section 5 should only be completed if electing Option 2: Rollover of Sheltered Contributions SECTION 5: FINANCIAL INSTITUTION AGREEMENT (Must be Completed by the Financial Institution) The receiving financial institution certifies that this account is an "Eligible Retirement Plan" created or organized in the USA, as defined by the Internal Revenue Code (IRC Sections 401(a)(31)(D), 402(c)(8)(A) and (B)). The receiving financial institution further certifies that the named account holder is the primary beneficiary and/or sole owner of this "Eligible Retirement Plan." Member's Signature Date

I have attached a copy of my Social Security card and have received agency certification from my most recent employing agency. I hereby acknowledge receipt of the attached multi-page document, "Special Tax Notice Regarding Plan Payments," which explains important tax information, options and effects of this transaction. I certify that to the best of my knowledge, all information provided is true and correct. I hereby authorize the Louisiana State Employees' Retirement System (LASERS) to direct this refunded accumulated contributions to my account at the financial institution designated in Section 3 or Section 5 of this form. This authorization is not an assignment of my right to receive payment and revokes all prior payment direction notifications applicable to this payment. Upon my death, if a payment has been deposited to my account that is not due, or if funds are credited to my account in error for any reason, I authorize: 1) LASERS to initiate electronic funds transfer debit transactions to retrieve the payment; and 2) The financial institution (bank or credit union) to release to LASERS the status of my account, my current mailing address, the names and mailing addresses of any joint account holder, and the names and mailing addresses of individuals who have power of attorney relevant to the payment to withdraw funds from my account. If my death should occur prior to the due date of any payment which is made by LASERS the named financial institution shall refund such payments to LASERS. I certify that I am entitled to the payment identified herein.

By signing below, I certify that I have read the provisions of this form, and fully understand the obligations contained herein. SECTION 3: ELECTRONIC TRANSFER ACCOUNT INFORMATION FOR OPTION 1 Check Mailing Address City

Office Area Code/Phone Number

SECTION 4: MEMBER SIGNATURE

Complete Section 3 only if electing Option 1: Contributions can only be refunded to the member and the bank account below must be in the member's name for the electronic transfer of funds to process. Name and Address of Financial Institution Type of Account: Routing Number Depositor Account Number Checking

Savings

Most Recent Terminated Agency

Yes, the monies will be deposited directly into a traditional IRA or another qualified employer plan Yes, the monies will be deposited into a Roth IRA. Yes, the monies will be deposited into an inherited IRA. The payment will be made payable to the financial institution, for the benefit

(FBO) of the inherited IRA. (Example: ING, FBO Jane Doe, beneficiary of John Doe IRA) Termination Date:

Month/Year

Form W-4R

2024

Withholding Certificate for Nonperiodic Payments and Eligible Rollover Distributions

Department of the Treasury

Internal Revenue Service

Give Form W-4R to the payer of your retirement payments. OMB No. 1545-0074

1a First name and middle initial Last name

Address

City or town, state, and ZIP code

1b Social security number

Your withholding rate is determined by the type of payment you will receive.

• For nonperiodic payments, the default withholding rate is 10%. You can choose to have a different rate by entering a rate between 0% and 100% on line 2. Generally, you can’t choose less than 10% for payments to be delivered outside the United States and its territories.

• For an eligible rollover distribution, the default withholding rate is 20%. You can choose a rate greater than 20% by entering the rate on line 2. You may not choose a rate less than 20%.

See page 2 for more information.

2

Complete this line if you would like a rate of withholding that is different from the default withholding rate. See the instructions on page 2 and the Marginal Rate Tables below for additional information. Enter the rate as a whole number (no decimals) . . . . . . . . . . . . . . . . . . . . . . . . 2 % Sign

Here

Your signature (This form is not valid unless you sign it.) Date General Instructions

Section references are to the Internal Revenue Code. Future developments. For the latest information about any future developments related to Form W-4R, such as legislation enacted after it was published, go to

www.irs.gov/FormW4R.

Purpose of form. Complete Form W-4R to have payers withhold the correct amount of federal income tax from your nonperiodic payment or eligible rollover distribution from an employer retirement plan, annuity (including a commercial annuity), or individual retirement arrangement (IRA). See page 2 for the rules and options that are available for each type of payment. Don’t use Form W-4R for periodic payments (payments made in installments at regular

intervals over a period of more than 1 year) from these plans or arrangements. Instead, use Form W-4P, Withholding Certificate for Periodic Pension or Annuity Payments. For more information on withholding, see Pub. 505, Tax Withholding and Estimated Tax.

Caution: If you have too little tax withheld, you will generally owe tax when you file your tax return and may owe a penalty unless you make timely payments of estimated tax. If too much tax is withheld, you will generally be due a refund when you file your tax return. Your withholding choice (or an election not to have withholding on a nonperiodic payment) will generally apply to any future payment from the same plan or IRA. Submit a new Form W-4R if you want to change your election.

2024 Marginal Rate Tables

You may use these tables to help you select the appropriate withholding rate for this payment or distribution. Add your income from all sources and use the column that matches your filing status to find the corresponding rate of withholding. See page 2 for more information on how to use this table.

Single

or

Married filing separately

Total income

over—

Tax rate for every

dollar more

$0 0%

14,600 10%

26,200 12%

61,750 22%

115,125 24%

206,550 32%

258,325 35%

623,950* 37%

* If married filing separately, use $380,200 instead for this 37% rate. Married filing jointly

or

Qualifying surviving spouse

Total income

over—

Tax rate for every

dollar more

$0 0%

29,200 10%

52,400 12%

123,500 22%

230,250 24%

413,100 32%

516,650 35%

760,400 37%

Head of household

Total income

over—

Tax rate for every

dollar more

$0 0%

21,900 10%

38,450 12%

85,000 22%

122,400 24%

213,850 32%

265,600 35%

631,250 37%

For Privacy Act and Paperwork Reduction Act Notice, see page 3. Cat. No. 75085T Form W-4R (2024) Form W-4R (2024) Page 2

General Instructions (continued)

Nonperiodic payments—10% withholding. Your payer must withhold at a default 10% rate from the taxable amount of nonperiodic payments unless you enter a different rate on line 2. Distributions from an IRA that are payable on demand are treated as nonperiodic payments. Note that the default rate of withholding may not be appropriate for your tax situation. You may choose to have no federal income tax withheld by entering

“-0-” on line 2. See the specific instructions below for more information. Generally, you are not permitted to elect to have federal income tax withheld at a rate of less than 10% (including

“-0-”) on any payments to be delivered outside the United States and its territories.

Note: If you don’t give Form W-4R to your payer, you don’t provide an SSN, or the IRS notifies the payer that you gave an incorrect SSN, then the payer must withhold 10% of the payment for federal income tax and can’t honor requests to have a lower

(or no) amount withheld. Generally, for payments that began before 2024, your current withholding election (or your default rate) remains in effect unless you submit a Form W-4R. Eligible rollover distributions—20% withholding.

Distributions you receive from qualified retirement plans (for example, 401(k) plans and section 457(b) plans maintained by a governmental employer) or tax-sheltered annuities that are eligible to be rolled over to an IRA or qualified plan are subject to a 20% default rate of withholding on the taxable amount of the distribution. You can’t choose withholding at a rate of less than 20% (including “-0-”). Note that the default rate of withholding may be too low for your tax situation. You may choose to enter a rate higher than 20% on line 2. Don’t give Form W-4R to your payer unless you want more than 20% withheld.

Note that the following payments are not eligible rollover distributions for purposes of these withholding rules:

• Qualifying “hardship” distributions;

• Distributions required by federal law, such as required minimum distributions;

• Generally, distributions from a pension-linked emergency savings account;

• Eligible distributions to a domestic abuse victim;

• Qualified disaster recovery distributions;

• Qualified birth or adoption distributions; and

• Emergency personal expense distributions.

See Pub. 505 for details. See also Nonperiodic payments—10% withholding above.

Payments to nonresident aliens and foreign estates. Do not use Form W-4R. See Pub. 515, Withholding of Tax on Nonresident Aliens and Foreign Entities, and Pub. 519, U.S. Tax Guide for Aliens, for more information.

Tax relief for victims of terrorist attacks. If your disability payments for injuries incurred as a direct result of a terrorist attack are not taxable, enter “-0-” on line 2. See Pub. 3920, Tax Relief for Victims of Terrorist Attacks, for more details. Specific Instructions

Line 1b

For an estate, enter the estate’s employer identification number

(EIN) in the area reserved for “Social security number.” Line 2

More withholding. If you want more than the default rate withheld from your payment, you may enter a higher rate on line 2.

Less withholding (nonperiodic payments only). If permitted, you may enter a lower rate on line 2 (including “-0-”) if you want less than the 10% default rate withheld from your payment. If you have already paid, or plan to pay, your tax on this payment through other withholding or estimated tax payments, you may want to enter “-0-”.

Suggestion for determining withholding. Consider using the Marginal Rate Tables on page 1 to help you select the appropriate withholding rate for this payment or distribution. The tables are most accurate if the appropriate amount of tax on all other sources of income, deductions, and credits has been paid through other withholding or estimated tax payments. If the appropriate amount of tax on those sources of income has not been paid through other withholding or estimated tax payments, you can pay that tax through withholding on this payment by entering a rate that is greater than the rate in the Marginal Rate Tables.

The marginal tax rate is the rate of tax on each additional dollar of income you receive above a particular amount of income. You can use the table for your filing status as a guide to find a rate of withholding for amounts above the total income level in the table.

To determine the appropriate rate of withholding from the table, do the following. Step 1: Find the rate that corresponds with your total income not including the payment. Step 2: Add your total income and the taxable amount of the payment and find the corresponding rate.

If these two rates are the same, enter that rate on line 2. (See Example 1 below.)

If the two rates differ, multiply (a) the amount in the lower rate bracket by the rate for that bracket, and (b) the amount in the higher rate bracket by the rate for that bracket. Add these two numbers; this is the expected tax for this payment. To get the rate to have withheld, divide this amount by the taxable amount of the payment. Round up to the next whole number and enter that rate on line 2. (See Example 2 below.)

If you prefer a simpler approach (but one that may lead to overwithholding), find the rate that corresponds to your total income including the payment and enter that rate on line 2. Examples. Assume the following facts for Examples 1 and 2. Your filing status is single. You expect the taxable amount of your payment to be $20,000. Appropriate amounts have been withheld for all other sources of income and any deductions or credits.

Example 1. You expect your total income to be $62,000 without the payment. Step 1: Because your total income without the payment, $62,000, is greater than $61,750 but less than

$115,125, the corresponding rate is 22%. Step 2: Because your total income with the payment, $82,000, is greater than $61,750 but less than $115,125, the corresponding rate is 22%. Because these two rates are the same, enter “22” on line 2. Example 2. You expect your total income to be $43,700 without the payment. Step 1: Because your total income without the payment, $43,700, is greater than $26,200 but less than

$61,750, the corresponding rate is 12%. Step 2: Because your total income with the payment, $63,700, is

Form W-4R (2024) Page 3

greater than $61,750 but less than $115,125, the corresponding rate is 22%. The two rates differ. $18,050 of the $20,000 payment is in the lower bracket ($61,750 less your total income of $43,700 without the payment), and $1,950 is in the higher bracket

($20,000 less the $18,050 that is in the lower bracket). Multiply

$18,050 by 12% to get $2,166. Multiply $1,950 by 22% to get

$429. The sum of these two amounts is $2,595. This is the estimated tax on your payment. This amount corresponds to 13% of the $20,000 payment ($2,595 divided by $20,000). Enter “13” on line 2.

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 additional federal income tax withholding from your nonperiodic payment(s) or eligible rollover distribution(s); (b) choose not to have federal income tax withheld from your nonperiodic payment(s), when permitted; or (c) change a previous Form W-4R (or a previous Form W-4P that you completed with respect to your nonperiodic payments or eligible rollover distributions). 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).

Failure to provide a properly completed form will result in your payment(s) being subject to the default rate; providing fraudulent information may subject you to penalties. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation, and to cities, states, the District of Columbia, and U.S. commonwealths and territories 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.

Special Tax Notice R032023 CONTINUE ON NEXT PAGE Page 1 of 7 SPECIAL TAX NOTICE REGARDING PLAN PAYMENTS

YOUR ROLLOVER OPTIONS

You are receiving this notice because all or a portion of a payment you are receiving from the Louisiana State Employees' Retirement System (the “Plan”) is eligible to be rolled over to an IRA or an employer plan. This notice is intended to help you decide whether to make such a rollover. This notice describes the rollover rules that apply to payments from the Plan that are not from a designated Roth account (a type of account with special tax rules in some employer plans). Rules that apply to most payments from a plan are described in the “General Information About Rollovers” section. Special rules that only apply in certain circumstances are described in the “Special Rules and Options” section.

GENERAL INFORMATION ABOUT ROLLOVERS

How can a rollover affect my taxes?

You will be taxed on a payment from the Plan if you do not roll it over. If you are under age 59 and do not execute a rollover, you will also have to pay a 10% additional income tax on early distributions (generally, distributions made before age 59 ), unless an exception applies. However, if you roll over, you will not have to pay tax until you receive payments later and the 10% additional income tax will not apply if those payments are made after you are age 59 (or if an exception to the 10% additional income tax applies). Where may I roll over the payment?

You may roll over the payment to either an IRA (an individual retirement account or individual retirement annuity) or an employer plan (a tax-qualified plan, section 403(b) plan, or governmental section 457(b) plan) that will accept the rollover. The rules of the IRA or employer plan that holds the rollover will determine your investment options, fees, and rights to payment from the IRA or employer plan (for example, no spousal consent rules apply to IRAs and IRAs may not provide loans). Further, the amount rolled over will become subject to the tax rules that apply to the IRA or employer plan. Special Tax Notice

R032023

How do I execute a rollover?

There are two ways to execute a rollover: a direct rollover or a 60-day rollover. If you execute a direct rollover, the Plan will make the payment directly to your IRA or an employer plan. You should contact the IRA sponsor or the administrator of the employer plan for information on how to accomplish a direct rollover.

If you do not perform a direct rollover, you may still roll over by making a deposit into an IRA or eligible employer plan that will accept it. Generally, you will have 60 days after you receive the payment to make the deposit. If you do not make a direct rollover, the Plan is required to withhold 20% of the payment for federal income taxes (up to the amount of cash and property received other than employer stock). This means that, in order to roll over the entire payment in a 60-day rollover, you must use other funds to make up for the 20% withheld. If you do not roll over the entire amount of the payment, the portion not rolled over will be taxed and will be subject to the 10% additional income tax on early distributions if you are under age 59 (unless an exception applies).

How much may I roll over?

If you wish to do a rollover, you may roll over all or part of the amount eligible for rollover. Any payment from the Plan is eligible for rollover, except:

· Certain payments spread over a period of at least 10 years or over your life or life expectancy (or the lives or joint life expectancy of you and your beneficiary)

· Required minimum distributions after age 73, or after death;

· Hardship distributions

· Corrective distributions of contributions that exceed tax law limitations

· Payments of certain automatic enrollment contributions requested to be withdrawn within 90 days of the first contribution

The Plan administrator or the payor can tell you what portion of a payment is eligible for rollover. If I do not execute a rollover, will I have to pay the 10% additional income tax on early distributions? If you are under age 59, you will have to pay the 10% additional income tax on early distributions for any payment from the Plan (including amounts withheld for income tax) that you do not roll over, unless one of the exceptions listed below applies. This tax applies to the part of the distribution that you must include in income and is in addition to the regular income tax on the payment not rolled over. Special Tax Notice R032023 CONTINUE ON NEXT PAGE Page 2 of 7 Special Tax Notice R032023 CONTINUE ON NEXT PAGE Page 3 of 7 The 10% additional income tax does not apply to the following payments from the Plan:

· Payments made after you separate from service if you will be at least age 55 in the year of the separation

· Payments that start after you separate from service if paid at least annually in equal or close to equal amounts over your life or life expectancy (or the lives or joint life expectancy of you and your beneficiary)

· Payments from a governmental defined benefit pension plan made after you separate from service if you are a public safety employee and you will be at least age 50 in the year of the separation

· Payments made due to disability

· Payments after your death

· Corrective distributions of contributions that exceed tax law limitations

· Payments made directly to the government to satisfy a federal tax levy

· Payments made under a qualified domestic relations order (QDRO)

· Payments up to the amount of your deductible medical expenses (without regard to whether you itemize deductions for the taxable year)

· Certain payments made while you are on active duty if you were a member of a reserve component called to duty after September 11, 2001 for more than 179 days

· Payments of certain automatic enrollment contributions requested to be withdrawn within 90 days of the first contribution

· Payments excepted from the additional income tax by federal legislation relating to certain emergencies and disasters; and

· Phased retirement payments made to federal employees. If I make a rollover to an IRA, will the 10% additional income tax apply to early distributions from the IRA?

If you receive a payment from an IRA when you are under age 59, you will have to pay the 10% additional income tax on early distributions on the part of the distribution that you must include in income, unless an exception applies. In general, the exceptions to the 10% additional income tax for early distributions from an IRA are the same as the exceptions listed above for early distributions from a plan. However, there are a few differences for payments from an IRA, including:

· There is no exception for payments after separation from service that are made after age 55 in the year of the separation (or age 50 for qualified public safety employees) does not apply.

· The exception for qualified domestic relations orders (QDROs) does not apply (although a special rule applies under which, as part of a divorce or separation agreement, a tax-free transfer may be made directly to an IRA of a spouse or former spouse).

· The exception for payments made at least annually in equal or close to equal amounts over a specified period applies without regard to whether you have had a separation from service.

· There are additional exceptions for (1) payments for qualified higher education expenses, (2) payments up to $10,000 used in a qualified first-time home purchase, and (3) payments for health insurance premiums after you have received unemployment compensation for 12 consecutive weeks (or would have been eligible to receive unemployment compensation but for self-employed status). Special Tax Notice R032023 CONTINUE ON NEXT PAGE Page 4 of 7 Will I owe State income taxes?

This notice does not describe any State or local income tax rules (including withholding rules). SPECIAL RULES AND OPTIONS

If your payment includes after-tax contributions

After-tax contributions included in a payment are not taxed. If a payment is only part of your benefit, an allocable portion of your after-tax contributions is generally included in the payment, so you cannot take a payment of only after-tax contributions. However, if you have pre-1987 after-tax contributions maintained in a separate account, a special rule may apply to determine whether the after-tax contributions are included in a payment. In addition, special rules apply when you do a rollover, as described below. You may roll over to an IRA a payment that includes after-tax contributions through either a direct rollover or a 60-day rollover. You must keep track of the aggregate amount of the after-tax contributions in all of your IRAs (in order to determine your taxable income for later payments from the IRAs). If you do a direct rollover of only a portion of the amount paid from the Plan and at the same time the rest is paid to you, the portion directly rolled over consists first of the amount that would be taxable if not rolled over. For example, assume you are receiving a distribution of $12,000, of which $2,000 is after-tax contributions. In this case, if you directly roll over

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