If the District of Columbia Retirement Board (DCRB) has determined that you are eligible to receive payment of unpaid/unexpended Plan contributions as a beneficiary of a deceased Teacher Plan member, you will complete this form. You must decide how your payment should be paid: (i) directly to you or (ii) a direct rollover to an IRA or another employer plan. A rollover allows you to postpone taxation of any portion of your payment that may be taxable to you when paid. Because your payment may include pre-tax contributions, you may be interested in doing a direct rollover to defer any taxation. Although post-tax contributions are not taxable to you when paid, you still may be interested in rolling over the post-tax contributions to an IRA or employer plan so future investment earnings on your rolled over post-tax payment grow tax-free. DCRB will provide a statement to you with the amount of payment and the tax treatment of the Plan contributions.

The Unpaid Deceased Member Contributions Payment application is to be used for lump-sum death benefit payments that constitute a refund of a deceased active, former or recently retired Teacher Plan member’s contributions. Do not use this application for a payment of the unpaid portion of a deceased retired Teacher Plan member’s retirement annuity.

Sign and date the application and return the original notarized application and any required documents to DCRB. Make a copy for your records.

Please note: this form must be signed in the presence of a Notary Public.

You can send the completed form and any required attachments by fax to (202) 566 -5001 or by mailing your documents to:

DC Retirement Board
Member Services Center
900 7th Street, NW, Second Floor
Washington, DC 20001

If you have further questions, please contact the DCRB Member Services Center by clicking on the Ask Member Services link, or by phone at (202) 343-3272 Monday – Friday from 8:30 am to 5:00 pm.