Instructions for Form 73b
** Complete all forms in capital letters (all CAPS) using BLACK ink. **
Please complete the above form and return it to the following address for
processing:
World Bank
Pension Administration
MSN MC7-710
1818 H Street, NW
Washington, DC 20433
Processing time for a lump sum benefit is 6 to 8 weeks after
your last day of service, provided that we are in receipt of your
duly completed Form 73b by your last day of service. If your
bank is located outside the United States, you must complete the
attached "SWIFT Form" (Form 2375_AU for Australia, Form
2375_F for France, Form 2375_G for Germany, Form 2375_UK
for the United Kingdom, or Form 2375 for other countries).
All U.S. tax residents or participants with U.S. address must
complete Form 2363 “Notification Concerning Direct Rollover" and
submit it with Form 73b to Pension Administration. U.S. nationals
and U.S. tax residents must also complete Form 70 “Lump Sum
Withdrawal Tax Supplement Application” and submit it directly to the
Tax Service Desk.
For additional information, contact Pension Administration:
Telephone: (202) 458-2977
E-mail: [email protected]
Facsimile: (202) 522-1723
73b (9-2009)
THE WORLD BANK GROUP
STAFF RETIREMENT PLAN
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APPLICATION FOR LUMP SUM BENEFIT IN LIEU OF A
PENSION (for participants joining on or after April 15, 1998)
Please refer to the Staff Retirement Plan (Plan) document or consult Pension Administration if you have questions.
Complete this form if you have met the Rule of 60 or have 10 or more years of Plan service and opt for a lump sum benefit.
Complete this form in capital letters (all CAPS) using BLACK ink.
Click here to clear form
1. APPLICANT
Nationality
Last Day of Bank Service (mm/dd/yy)
UPI No.
Name (Last, First, M.I.)
Marital Status
Single
Married
Separated
Divorced
Widowed
2. SPOUSE/REGISTERED DOMESTIC PARTNER (DP)
Name (Last, First, M.I.)
Date of Marriage/Partnership
(mm/dd/yy)
Date of Birth (mm/dd/yy)
Nationality
Signature of Spouse/DP
3. CURRENCY ELECTION FOR DEFINED BENEFIT AND TERMINATION GRANT
I elect to receive my entire Plan benefit (Defined Benefit and Termination Grant for eligible national staff1/) in the following currency:
* It is your responsibility to ensure that receiving your Benefit in the above
elected currency will not violate any applicable foreign exchange regulations
in your country. The incurred transaction cost and/or conversion cost will be
paid by the participant.
U.S. dollars*
Non-U.S. dollars (specify)*
1/
If you are holding a Local Regular or Local Fixed-Term appointment prior to April 15, 1998 and if you have at least 10 years combined SRP
(Defined Benefit Plan) service and Termination Grant Service, you have the option to convert all of these lump-sum benefits into an annuity.
Please contact Pension Administration for further information. Do not complete this form to receive a monthly pension (annuity).
4. INSTRUCTION FOR PAYMENT OF LUMP SUM AMOUNTS (for Defined Benefit and Termination Grant)
Indicate the account to which payment should be directed in part (a) below. You may designate an eligible retirement account or employer plan to receive an optional
direct rollover of your lump sum benefit. Please also complete form 2363, “Notice Concerning Direct Rollover,” if residing in the U.S. at the time of distribution and/or U.S.
tax resident. Rollover is applicable only if the currency of payment is in U.S. dollars.
A. For Total Payment or Portion Not Rolled Over
Bank's ABA No. (if bank is in the US)
Account No.
B. For Optional Direct Rollover of Benefit Payable by Paper Check
and Sent to You by Courier Service
Amount of Rollover
Taxable portion only
Benefits will be paid only to the bank account
held in the name of the participant.
Bank's SWIFT/BIC (provided by your bank)
IBAN No. (if bank is in Europe)
100% - taxable & non-taxable portion
Other (specify amount)
Traditional IRA
Account Type
$
Roth IRA
Keogh
Employer Plan
Account No.
Checking
Other (specify)
Bank Name
Trustee (Financial Institution)
Bank Address
Address
73b (9-2009)
5. CURRENCY ELECTION FOR CASH BALANCE AND VOLUNTARY SAVINGS
I elect to receive my entire Plan benefit (Cash Balance and Voluntary Savings) in the following currency:
(in the absence of an election, your Plan benefit will be paid in U.S. dollars)
* It is your responsibility to ensure that receiving your Benefit in the above
elected currency will not violate any applicable foreign exchange regulations
in your country. The incurred transaction cost and/or conversion cost will be
paid by the participant.
U.S. dollars*
Non-U.S. dollars (specify)*
If both payments are in the same currency, we will use the same banking information as provided above.
6. INSTRUCTION FOR PAYMENT OF LUMP SUM AMOUNTS (for Cash Balance and Voluntary Savings)
Indicate the account to which payment should be directed in part (a) below. You may designate an eligible retirement account or employer plan to receive an optional
direct rollover of your lump sum benefit. Please also complete form 2363, “Notice Concerning Direct Rollover,” if residing in the U.S. at the time of distribution and/or U.S.
tax resident. Rollover is applicable only if the currency of payment is in U.S. dollars.
B. For Optional Direct Rollover of Benefit Payable by Paper Check
and Sent to You by Courier Service
A. For Total Payment or Portion Not Rolled Over
Bank's ABA No. (if bank is in the US)
Account No.
Amount of Rollover
Taxable portion only
Benefits will be paid only to the bank account
held in the name of the participant.
Bank's SWIFT/BIC (provided by your bank)
100% - taxable & non-taxable portion
Other (specify amount)
IBAN No. (if bank is in Europe)
Traditional IRA
Account Type
$
Roth IRA
Keogh
Employer Plan
Account No.
Checking
Other (specify)
Bank Name
Trustee (Financial Institution)
Bank Address
Address
7. TAX STATUS (check one box)
Indicate your tax status at the time you will receive your Plan benefit by checking the appropriate box. If you are taxable in the U.S., or any other
country, complete form 70. Please also complete form 2363, “Notice Concerning Direct Rollover,” if residing in the U.S. at the time of distribution
and/or U.S. tax resident.
I am, or will be, a U.S. citizen or a U.S. Permanent Resident. My U.S. social security no. is
If U.S. citizen, check one:
From birth, or
As of (date)
I will be a U.S. resident for income tax purposes due to "substantial presence test." My U.S. social security no. is
My benefit will be taxable in (country)
My benefit will not be taxable in the U.S. or any other country
8. MAILING ADDRESS
Telephone No.
Personal E-mail Address
Fax No.
Address
Street
City
State
Zip/Country
Under the provision of the Plan, I am entitled to and hereby elect to cease to be a participant as of (mm/dd/yy)
and to receive a lump sum benefit in lieu of a pension. I surrender and waive, from the date that I cease to be a participant, all other rights under the
Plan including death benefit, for myself, my beneficiaries, and persons claiming through or under me.
Spousal Consent Signature
Date
Applicant's Signature
Date
73b (9-2009)
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THE WORLD BANK GROUP
STAFF RETIREMENT PLAN
SWIFT FORM (only for banks in Australia)
To be completed by the beneficiary with the assistance of their bank.
Pensioner's Name (please print)
Effective Date of Change
Pensioner's Signature
UPI/Staff No.
Date
Our bank is a member of the Society for WorldWide InterBank Financial Telecommunications (SWIFT)
Payment currency: US dollars
Account No.
BSB
Bank Name
Bank Address
Fax No.
Telex No.
SWIFT/Bank Identifier Code (BIC)
Intermediary ABA No.
Intermediary Bank via FED WIRE
Intermediary Bank Address (include city and country)
Payment currency: non-US dollars.
Currency Name
Account No.
BSB
Bank Name
Bank Address
Fax No.
Telex No.
SWIFT/Bank Identifier Code (BIC) - including branch code
Intermediary BIC Code
Intermediary Bank
Intermediary Bank Address (include city and country)
Please return this form to:
Pension Administration Division
World Bank
1818 H Street, NW, MSN MC7-710
Washington, DC 20433
Keep a copy of this completed form for your records.
2375_AU (8-2008)
Fill in screen, then print before moving to next page.
THE WORLD BANK GROUP
STAFF RETIREMENT PLAN
SWIFT FORM (only for banks in France)
To be completed by the beneficiary with the assistance of their bank.
Pensioner's Name (please print)
Effective Date of Change
Pensioner's Signature
UPI/Staff No.
Date
Our bank is a member of the Society for WorldWide InterBank Financial Telecommunications (SWIFT)
Payment currency: US dollars
Code banque
Code guichet
No. compte
Clé RIB
Bank Name
Domiciliation
IBAN No.
Bank Address
Fax No.
Telex No.
SWIFT/Bank Identifier Code (BIC)
Intermediary ABA No.
Intermediary Bank via FED WIRE
Intermediary Bank Address (include city and country)
Payment currency: non-US dollars.
Code banque
Code guichet
Currency Name
No. compte
Clé RIB
Domiciliation
IBAN No.
Bank Name
Bank Address
Fax No.
Telex No.
SWIFT/Bank Identifier Code (BIC) - including branch code
Intermediary BIC Code
Intermediary Bank
Intermediary Bank Address (include city and country)
Please return this form to:
Pension Administration Division
World Bank
1818 H Street, NW, MSN MC7-710
Washington, DC 20433
Keep a copy of this completed form for your records.
2375_F (8-2008)
Fill in screen, then print before moving to next page.
THE WORLD BANK GROUP
STAFF RETIREMENT PLAN
SWIFT FORM (only for banks in Germany)
To be completed by the beneficiary with the assistance of their bank.
Effective Date of Change
Pensioner's Name (please print)
Pensioner's Signature
UPI/Staff No.
Date
Our bank is a member of the Society for WorldWide InterBank Financial Telecommunications (SWIFT)
Payment currency: US dollars
Account No.
IBAN No.
BLZ
Bank Name
Bank Address
Fax No.
Telex No.
SWIFT/Bank Identifier Code
(BIC)
Intermediary ABA No.
Intermediary Bank via FED WIRE
Intermediary Bank Address (include city and country)
Payment currency: non-US dollars.
Currency Name
Account No.
IBAN No.
BLZ
Bank Name
Bank Address
Fax No.
Telex No.
SWIFT/Bank Identifier Code (BIC) - including branch code
Intermediary BIC Code
Intermediary Bank
Intermediary Bank Address (include city and country)
Please return this form to:
Pension Administration Division
World Bank
1818 H Street, NW, MSN MC7-710
Washington, DC 20433
Keep a copy of this completed form for your records.
2375_G (8-2008)
Fill in screen, then print before moving to next page.
THE WORLD BANK GROUP
STAFF RETIREMENT PLAN
SWIFT FORM (only for banks in the United Kingdom)
To be completed by the beneficiary with the assistance of their bank.
Pensioner's Name (please print)
Effective Date of Change
Pensioner's Signature
UPI/Staff No.
Date
Our bank is a member of the Society for WorldWide InterBank Financial Telecommunications (SWIFT)
Payment currency: US dollars
IBAN No.
Sort Code
Account No.
Bank Name
Bank Address
Fax No.
Telex No.
SWIFT/Bank Identifier Code (BIC)
Intermediary ABA No.
Intermediary Bank via FED WIRE
Intermediary Bank Address (include city and country)
Payment currency: non-US dollars.
Account No.
Currency Name
IBAN No.
Sort Code
Bank Name
Bank Address
Fax No.
Telex No.
SWIFT/Bank Identifier Code (BIC) - including branch code
Intermediary BIC Code
Intermediary Bank
Intermediary Bank Address (include city and country)
Please return this form to:
Pension Administration Division
World Bank
1818 H Street, NW, MSN MC7-710
Washington, DC 20433
Keep a copy of this completed form for your records.
2375_UK (8-2008)
Fill in screen, then print before moving to next page.
THE WORLD BANK GROUP
STAFF RETIREMENT PLAN
SWIFT FORM (only for banks outside U.S.)
To be completed by the beneficiary with the assistance of their bank.
Pensioner's Name (please print)
Effective Date of Change
Pensioner's Signature
UPI/Staff No.
Date
Our bank is a member of the Society for WorldWide InterBank Financial Telecommunications (SWIFT)
Payment currency: US dollars
IBAN No. (if bank is in Europe)
Account No.
Bank Name
Bank Address
Fax No.
Telex No.
SWIFT/Bank Identifier Code (BIC)
Intermediary ABA No.
Intermediary Bank via FED WIRE
Intermediary Bank Address (include city and country)
Payment currency: non-US dollars.
Currency Name
IBAN No. (if bank is in Europe)
Account No.
Bank Name
Bank Address
Fax No.
Telex No.
SWIFT/Bank Identifier Code (BIC) - including branch code
Intermediary BIC Code
Intermediary Bank
Intermediary Bank Address (include city and country)
Please return this form to:
Pension Administration Division
World Bank
1818 H Street, NW, MSN MC7-710
Washington, DC 20433
Keep a copy of this completed form for your records.
2375 (8-2008)
Do not write in this space
THE WORLD BANK GROUP
STAFF RETIREMENT PLAN
NOTICE CONCERNING DIRECT ROLLOVER
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This notice is only for participants, surviving spouses, former spouses or beneficiaries receiving
lump sum benefit(s) from the Staff Retirement Plan if they are U.S. citizens, U.S. residents for income tax
purposes, or non-residents residing in the U.S. at the time of distribution.
Note:
Some U.S. tax rules may apply to the payment of your lump sum benefit(s). To determine the course of
action most suitable for you, consult a professional tax advisor. You should also review IRS Publication 575,
“Pension and Annuity Income,” and IRS Publication 590, “Individual Retirement Arrangement,” available
on the IRS's Web Site, www.irs.gov, or by calling 1-800-TAX-FORMS.
If you are a U.S. national or a resident for U.S.
income tax purposes at the time you receive your payment
from the Staff Retirement Plan (SRP), a portion of your
lump sum benefit will be non-taxable, and the remainder
will be taxable under U.S. income tax law. If you are a
non-resident for income tax purposes, your entire benefit
may be nontaxable in the U.S. (Pension Administration
will provide you with tax information upon request.)
Additionally, if you are an SRP participant and you
terminate from the Bank Group before the calendar year in
which you reach age 55 and are under age 59½ when a
distribution is paid to you, you may have to pay an
additional 10% tax on any part that you do not roll over.
See Tax on Early Distributions in Publication 575.
You may defer payment of U.S. income tax and
avoid any 10% additional tax by rolling over all or part of
your benefit into an Individual Retirement Arrangement
(IRA), including a Keogh or self-employed retirement
arrangement, or a retirement plan of another employer that
accepts rollovers. You can establish a new IRA to receive
the rollover. Please note that your benefit cannot be rolled
over to a Designated Roth Account, a SIMPLE IRA or a
Coverdell Education Savings Account.
You will not be subject to tax on the rolled over
amounts until they are later paid to you from the IRA or
plan that accepts the rollover. Depending on the type of
plan, the later distribution may be subject to different tax
treatment than it would be if your SRP benefit were taxed
now.
If you rollover an amount in excess of the taxable portion
of your benefit, you will need to keep track of this excess amount
and report it to the Internal Revenue Service as necessary to ensure
that it will not be subject to tax when it is later distributed from the
IRA or plan. Some employer plans will not accept a rollover in
excess of the taxable portion. Additionally, if you rollover the
excess amount into an IRA, you cannot subsequently transfer that
amount to an employer plan.
There are two ways to rollover your benefit:
1. If the entire benefit is paid directly to you, you may transfer all
or part of it to one or more IRAs and/or an employer plan, provided
that you do so within 60 days after the date you receive the payment
from the SRP. Please note that because of the Bank’s immunities,
income tax will not be withheld from this payment.
2. Alternatively, you may direct the SRP to rollover all or part of
your benefit directly to one IRA or employer plan that you
designate. If you designate an employer plan under this option, you
must contact the administrator of that plan to determine if it will
accept your rollover. If you elect this option, the SRP will mail you
a check payable to the trustee of the designated IRA or plan for the
amount you wish to rollover. You will then need to forward that
check to the trustee. The remainder of your benefit will be paid
directly to you.
You may take up to 30 days after receipt of this notice to
consider a direct rollover from the SRP of all or part of your
payment. However, you may make a decision sooner by checking
the appropriate box below:
Make payment of my lump sum benefit(s) in accordance with my payment instructions. I have either used up to 30 days
following receipt of this notice or am waiving my right to use up to 30 days following receipt of this notice to consider my
rollover options discussed above.
I have elected to receive my lump sum benefit(s), but wish to delay my decision on the direct rollover option for up to 30 days
following receipt of this notice. I also understand that the payment of my lump sum benefit(s) will be delayed until I decide whether
I wish a direct transfer and so instruct Pension Administration. If I fail to elect or decline a direct transfer within the 30-day period,
Pension Administration shall conclude that I have declined a direct transfer and shall pay the entire lump sum benefit(s) in
accordance with my payment instructions.
To process payment of your lump sum benefit(s), this form must be signed.
I acknowledge reading the Notice Concerning Direct Rollover above and the attached Rollover Provisions
for Lump Sum Benefit(s).
Applicant's Signature
UPI/Staff No.
Keep a copy of this completed form for your records.
Date
2363 (9-2008)
ROLLOVER PROVISIONS FOR LUMP SUM BENEFIT(S)
You should consider the following important information regarding treatment of the
taxable portion of the lump sum benefit(s) under the Staff Retirement Plan.
A portion of your lump sum benefit(s) will be taxable under United States income tax
law. It is possible to defer payment of U.S. income tax by rolling over all or part of the taxable
amount of your benefit into an Individual Retirement Arrangement (IRA) of a retirement plan
of another employer that accepts rollovers. You will not be subject to tax on the rolled over
amounts until they are later paid to you from the IRA or employer retirement plan.
If the entire lump sum benefit(s) is paid directly to you, you may transfer all or part of the
taxable amount to one or more IRAs and/or an employer plan provided that you do so within 60
days of the date you receive the payment from the Staff Retirement Plan. You may also rollover
an amount exceeding your taxable amount, but if you do, you will need to keep track of this
excess amount and report it to the Internal Revenue Service. This will ensure that it will not be
subject to tax when it is later withdrawn from an IRA or pension plan. If the excess is rolled
over an IRA, it may not be possible to transfer it back to an employer plan at a later date.
You can open an IRA to receive the rollover; or, if you become self-employed, you can
establish a Keogh or self-employed retirement plan to receive the rollover.
Any part of the taxable amount of your benefit that is paid to you and not rolled over
within 60 days will be subject to income tax in the year in which you receive the payment. You
may also be subject to a 10% additional tax in the year in which you receive the payment. You
may also be subject to a 10% additional tax on early distributions in the event you did not attain
age 55 before or during the year in which you separated from the Bank Group.
This notice is only a summary of some of the U.S. tax rules that might apply to your
payment. For assistance in determining the action most suitable to you, consultation with a
professional tax adviser is strongly recommended.
Keep a copy of this completed form for your records.
2363 (9-2008)