A Guide to Completing Your CalPERS
Service Retirement Election Application
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TABLE OF CONTENTS
Introduction .............................................3
Retirement Planning Resources ...........................4
Key Points to Consider Before You Retire ...................5
Other Considerations ..................................... 6
If You Become Disabled
..................................6
Power of Attorney
......................................6
Emergency Retirement
..................................6
Divorce, Legal Separation, or Termination of Domestic Partnership
..6
Working After You Retire
.................................7
Benefit Forfeiture for Felony Convictions
.....................7
How to Complete Your Service Retirement
Election Application ......................................8
What Happens Next?
.................................. 18
Supporting Documents ..................................20
Retirement Forms ....................................... 21
Retirement Allowance Estimate Request Form
................. 21
Service Retirement Election Application Form
................. 23
Justification for Absence of Spouses or Registered Domestic
Partner’s Signature Form
............................. 33
CalPERS Health Benefits ................................. 35
Health Insurance Covered Under PEMHCA
................. 35
Medicare
............................................ 36
Dental Coverage and Vesting Requirements
(State and CSU Members Only)
........................ 38
Vision Care (State and CSU Members Only)
................. 39
Long-Term Care
...................................... 39
Taxes and Your Service Retirement ....................... 40
1099-R Annual Tax Reporting Statement
.................... 40
Calculating the Monthly Tax-Free Portion of Your
Retirement Allowance
................................ 40
Federal Tax Considerations
.............................. 42
California State Taxes
.................................. 42
Tax Withholding Election
............................... 42
Become a More Informed Member ........................ 43
CalPERS Website
..................................... 43
myCalPERS
......................................... 43
CalPERS Education Center
.............................. 43
Experience CalPERS Through Social Media
.................. 43
Reach Us by Phone
.................................... 43
Visit Your Nearest CalPERS Regional Office
.................. 44
Important Information for Regional Office Visits
.............. 45
Privacy Notice .......................................... 46
2 888 CalPERS (or 888-225-7377)
3www.calpers.ca.gov
INTRODUCTION
This publication provides instructions for completing the CalPERS Service
Retirement Election Application and other forms you may need to complete
the retirement application process. You may also complete the application
process through your personal myCalPERS account at my.calpers.ca.gov.
Easy-to-follow instructions will guide you step-by-step through the online
application. You can submit your paper or online application when you are
within 120 days from your retirement date.
For more information
about your retirement
benefits, visit our website
at www.calpers.ca.gov.
4 888 CalPERS (or 888-225-7377)
RETIREMENT PLANNING RESOURCES
CalPERS has many resources available to help you plan for retirement:
CalPERS website at www.calpers.ca.gov
Your personal myCalPERS account at my.calpers.ca.gov
Online and instructor-led retirement classes
Webinars and YouTube videos
Member publications
One-on-one retirement counseling
Official retirement estimates
Our publication Planning Your Service Retirement (PUB 1) contains detailed
information about how we calculate your benefit, ways to increase your benefit,
and other factors you’ll want to consider before you retire. You can find this
publication and others in the Forms & Publications area of our website at
www.calpers.ca.gov.
If you havent already received a retirement estimate, we strongly encourage you
get one before you retire. If youre within 12 months of your retirement date,
complete and mail the Retirement Allowance Estimate Request form located in
this publication. You can also generate and save estimates through your personal
myCalPERS account at my.calpers.ca.gov. This calculator allows you to enter
a variety of beneficiary and survivor scenarios and uses your actual account
information to project your future benefit.
You can look at your latest Annual Member Statement to ensure we have
the correct employment history for you. Your statements are available at
my.calpers.ca.gov.
5www.calpers.ca.gov
KEY POINTS TO CONSIDER BEFORE YOU RETIRE
If youre eligible to receive Social Security benefits and worked for
an employer that didnt withhold Social Security taxes, the Windfall
Elimination Provision and Government Pension Offset can reduce your
Social Security benefits. To learn more about these offsets please call the
Social Security Administration at (800) 772-1213 or visit their website
at www.ssa.gov.
You must stop working in all CalPERS-covered employment before your
retirement date, including all full-time and part-time positions and any
elected or appointed offices for which you have CalPERS membership.
Tell your CalPERS employer(s) of your planned retirement date so they
can submit permanent separation information on your behalf. If they dont
tell us you stopped working, you may be considered unlawfully employed
and you may have to repay any overpaid retirement benefits.
You must submit your retirement application within nine months of
leaving CalPERS employment or separating from another California public
retirement system to be eligible for the earliest possible retirement date.
If not, your retirement date can be no earlier than the first of the month
in which CalPERS receives your application.
If you plan to purchase service credit, you must request a cost packet, make
the election, and pay your service credit purchase in full before your planned
retirement date. If the balance is not paid in full prior to retirement, your
retirement allowance will be reduced by the actuarial equivalent of the
balance. To learn more, refer to A Guide to Your CalPERS Service Credit
Purchase Options (PUB 12) and A Guide to Your CalPERS Military
Service Credit Options (PUB 15).
Completing separation or retirement forms with your employer does not
retire you from CalPERS. Your CalPERS retirement account is separate
and you must submit a Service Retirement Election Application to complete
the retirement process.
If your employer contracts for retiree health benefits, your retirement date
must be within 120 days of leaving employment to be eligible to receive
retiree health benefits.
You cannot make changes to your retirement application more than
30 days after your first retirement check is issued. This includes canceling
your retirement application, changing your retirement date, changing
the retirement payment option you select, or changing the beneficiary
(or beneficiaries) you name to receive an ongoing monthly benefit, if any.
6 888 CalPERS (or 888-225-7377)
OTHER CONSIDERATIONS
If You Become Disabled
If you are disabled and can no longer perform the duties of your job, you may
qualify for disability retirement or industrial disability retirement. Learn about
the eligibility requirements in our publication A Guide to Completing Your
Disability Retirement Election Application (PUB 35).
Power of Attorney
A CalPERS special power of attorney allows you to designate a representative
or agent, known as your attorney-in-fact, to conduct your retirement affairs.
Should you become unable to act on your own behalf, your designated
attorney-in-fact will be able to perform important duties concerning your
CalPERS business, such as address changes, federal or state tax withholding
elections, and retirement benefit elections.
The CalPERS special power of attorney is specifically designed for use by active
and retired CalPERS members and beneficiaries. You may already have a power
of attorney set up through another resource; however, it may not address your
CalPERS retirement benefits. For more information, review the publication
A Guide to the CalPERS Special Power of Attorney (PUB 30).
Emergency Retirement
If you are terminally ill, facing imminent death, or about to have surgery,
please call us toll free at 888 CalPERS (or 888-225-7377) to discuss what
options are available to you.
Divorce, Legal Separation, or Termination
of Domestic Partnership
If you have a community property claim on your retirement account, a hold
is placed on your account and benefits are held until the claim is resolved.
We recommend that you resolve the claim before you retire to avoid possible
delays in processing your retirement benefits. However, you should not wait
to submit your retirement application. Waiting to apply for retirement may
affect the retirement date and other benefits you are entitled to receive. For
more information, review the publication A Guide to CalPERS Community
Property (PUB 38A). If you are not sure whether your claim has been resolved
or have questions about your court order or your benefits, please call us toll
free at 888 CalPERS (or 888-225-7377).
7www.calpers.ca.gov
Working After You Retire
There are rules and restrictions related to working after retirement. Before
accepting any position, read the publications A Guide to CalPERS Employment
After Retirement (PUB 33) and A Guide to CalPERS Reinstatement From
Retirement (PUB 37) regarding the requirements and limitations.
Benefit Forfeiture for Felony Convictions
Under the California Public Employees’ Pension Reform Act of 2013, if you
are convicted of a felony by a state or federal trial court in connection with
your official job duties, you will forfeit all of your accrued rights and benefits
from the commission of the felony forward and you will no longer be eligible
to accrue further benefits with CalPERS, effective on the date of conviction
(Government Code sections 7522.72 and 7522.74).
If you are convicted for such a crime, you and the prosecuting agency must
notify your employer within 60 days of your conviction, and your employer
must notify CalPERS within 90 days of your conviction.
CalPERS will remove the service credit and return any contributions you made
during the forfeiture period, without interest. If after the removal of forfeited
service and contributions you remain vested for retirement, you may apply
for retirement once you reach minimum retirement age. If after the removal
of forfeited service you are not vested for retirement, you may elect a refund
of your remaining member contributions.
Should your conviction be overturned, your forfeited service will be restored to
your account if you elect to redeposit the returned contributions, with interest.
8 888 CalPERS (or 888-225-7377)
HOW TO COMPLETE YOUR SERVICE RETIREMENT
ELECTION APPLICATION
Remove the Service Retirement Election Application form from this
publication so you can follow the step-by-step instructions for each section
while you are completing it. You can also log in to your myCalPERS account
at my.calpers.ca.gov to submit your application online.
Section 1 – Information About You
Complete all fields with your personal information.
If you have changed your name, you must provide CalPERS with a
photocopy of the document validating the change (marriage certificate,
court order, etc.). Additionally, the IRS requires us to obtain a photocopy
of your updated Social Security card containing your new name before
we can stop using your former name.
By providing your email address, you are agreeing to receive occasional
CalPERS email notifications.
Section 2 – Information About Your Retirement
Complete all fields with your retirement information.
Your retirement date can be effective any day of the week, including Saturday
or Sunday. It should be the day following your last day of work or authorized
paid leave of absence.
The effective date of your retirement can be no earlier than the
day following your last day on payroll, as long as your application
is received by CalPERS within nine months of that date. If not,
the retirement date can be no earlier than the first of the month
in which CalPERS receives your application. If you elected to
purchase service credit, your retirement date can be no earlier
than the day following your service credit purchase election.
If you are employed in
more than one position
under CalPERS, even
if the other position is
considered overtime and
not reportable to CalPERS,
you must separate from
all employment to retire.
9www.calpers.ca.gov
Temporary Annuity
If you elect to receive the temporary annuity benefit, complete all fields based
on your membership date.
If your membership date is prior to January 1, 2002, enter the age at which
you want the temporary annuity benefit to stop—age 59½ or any whole
age from 60 to 68. The temporary annuity amount you request is not
dependent on your estimated Social Security benefit.
If your membership date is January 1, 2002, or later, enter the age at
which you want the temporary annuity benefit to stop—whole age from
62 to 70. You must have CalPERS service coordinated with Social Security
to be eligible, and the amount you request cannot exceed your estimated
Social Security benefit. You must request an estimate of your Social Security
benefits from the Social Security Administration prior to submitting your
CalPERS retirement application.
You must name a beneficiary for the temporary annuity balance in Section 4c
of the application. You can also request an estimate for temporary annuity by
using the Retirement Allowance Estimate Request form in this publication.
For more information, refer to A Guide to Your CalPERS Temporary Annuity
(PUB 13).
Other California Public Retirement Systems
If you are a member of a defined benefit plan with another California public
retirement system, your CalPERS retirement date must be the same as the
retirement date from the other system to receive the highest possible benefit
amount. You must submit a retirement application to each system. And you
must submit your retirement application within nine months of leaving
CalPERS employment or separating from another California public retirement
system. Otherwise, the retirement date can be no earlier than the first of the
month in which CalPERS receives your application. For more information,
refer to A Guide to CalPERS When You Change Retirement Systems
(PUB 16).
The temporary annuity
benefit is additional
monthly income you
may choose to enhance
your pension from
CalPERS. This benefit is
funded through a lifetime
reduction of your monthly
retirement allowance.
10 888 CalPERS (or 888-225-7377)
Section 3 – Select Your Retirement Payment Option
Choose one retirement payment option. Your choice becomes irrevocable
30 days from the issuance of your first retirement check. See below for
a description of the available options.
Retirement
Payment
Option
For You For Your Beneficiary
Unmodified
Allowance
Provides the highest
monthly allowance paid
for life.
There is no continuing
monthly benefit to a
beneficiary and no return
of unused member
contributions upon
your death.
Return of
Remaining
Contributions
Option 1*
Only available if you paid
contributions to CalPERS.
Can name one or more
beneficiaries.
Does not provide ongoing
monthly benefit.
Upon your death, provides
a lump-sum payout of
any remaining member
contributions in your
account to one or more
named beneficiaries.
If no remaining member
contributions, no benefit
is paid.
100 Percent
Beneficiary
Option 2*
Can name only one
beneficiary for an
ongoing monthly benefit.
Can name one or more
beneficiaries for the lump-
sum portion.
Provides 100 percent
of the option portion of
your ongoing monthly
benefit to your named
beneficiary upon your
death.
Upon both your deaths,
a lump-sum payout of
any remaining member
contributions in your
account will be paid to
one or more named
secondary beneficiaries.
100 Percent
Beneficiary
Option 2
with Benefit
Allowance
Increase
Can name only one
beneficiary.
If your beneficiary dies
before you, or you have
another qualifying event,
your benefit will increase
to the Unmodified
Allowance.
Provides 100 percent of
the option portion of your
ongoing monthly benefit
to your named beneficiary
upon your death.
* It takes about 10 years of retirement to totally deplete your contributions, but your
monthly benefit continues.
11www.calpers.ca.gov
Retirement
Payment
Option
For You For Your Beneficiary
50 Percent
Beneficiary
Option 3*
Can name only one
beneficiary for an
ongoing monthly benefit.
Can name one or more
beneficiaries for the
lump-sum portion.
Provides 50 percent of
the option portion of
your ongoing monthly
benefit to your named
beneficiary upon your
death.
Upon both your deaths,
a lump-sum payout of
any remaining member
contributions in your
account will be paid to
one or more named
secondary beneficiaries.
50 Percent
Beneficiary
Option 3
with Benefit
Allowance
Increase
Can name only one
beneficiary.
If your beneficiary dies
before you, or you have
another qualifying event,
your benefit will increase
to the Unmodified
Allowance.
Provides 50 percent of
the option portion of your
ongoing monthly benefit
to your named beneficiary
upon your death.
Flexible
Beneficiary
Option 4
Can name one or more
beneficiaries.
Can specify a specific
dollar or percentage be
paid to each beneficiary.
Provides an ongoing
monthly benefit of a
specific percentage or
specific dollar amount of
your Unmodified Allowance
to one or more named
beneficiaries upon your
death.
* It takes about 10 years of retirement to totally deplete your contributions, but your
monthly benefit continues.
12 888 CalPERS (or 888-225-7377)
If you are required by a court order to designate your nonmember spouse
or domestic partner for an ongoing monthly benefit, fill in your former
spouse/partner’s name and Social Security number or CalPERS ID, and
then choose one of the following Court-Ordered Community Property
Option 4 options for your share of the benefit.
Retirement
Payment
Option
For You For Your Beneficiary
Court-Ordered
Community
Property
Option 4 /
Unmodified
Allowance
For your remaining share,
provides you the highest
monthly allowance paid for
your lifetime.
Provides an ongoing
monthly benefit to your
nonmember spouse or
domestic partner equal
to his or her community
property interest.
There is no return of
unused member
contributions upon
your death.
Court-Ordered
Community
Property
Option 4 /
Return of
Remaining
Contributions
Option 1*
Only available if you paid
contributions to CalPERS.
Can name one or more
beneficiaries for the
lump-sum portion of your
remaining share.
Provides an ongoing
monthly benefit to your
nonmember spouse or
domestic partner equal
to his or her community
property interest.
For your remaining share,
provides a lump-sum
payout of any remaining
member contributions
in your account to
one or more named
beneficiaries.
Court-Ordered
Community
Property
Option 4 /
Specific
Percentage or
Specific Dollar
Amount
Can name one or more
beneficiaries for your
remaining share.
Can specify a specific
dollar or percentage be
paid to each beneficiary.
Provides an ongoing
monthly benefit to your
nonmember spouse or
domestic partner equal
to his or her community
property interest.
For your remaining share,
provides an ongoing
monthly benefit of a
specific percentage or
specific dollar amount
of your Unmodified
Allowance to one or more
named beneficiaries upon
your death.
* It takes about 10 years of retirement to totally deplete your contributions, but your
monthly benefit continues.
13www.calpers.ca.gov
Section 4a – Complete Your Beneficiary Information –
Ongoing Monthly Benefit
Complete all fields. The beneficiary you name to receive an ongoing monthly
benefit becomes irrevocable 30 days from the date your first retirement check
is issued unless you have a future qualifying event.
For more information about qualifying life events, refer to our publication
Changing Your Beneficiary or Monthly Benefit After Retirement (PUB 98).
You must submit birth date evidence for your named beneficiary. If your
beneficiary is your spouse and there is a Survivor Continuance benefit, you
must also submit evidence of marriage. For a list of acceptable documents,
refer to “Supporting Documents” on page 20.
Section 4b – Complete Your Beneficiary Information –
Specific Percentage or Specific Dollar Amount
Complete all fields for each beneficiary you name. Any beneficiary you name
in this section becomes irrevocable 30 days from the date your first retirement
check is issued unless you have a future qualifying event.
For more information about qualifying life events, refer to our publication
Changing Your Beneficiary or Monthly Benefit After Retirement (PUB 98).
Specify either a specific percentage or dollar amount, or leave the fields blank
if you are naming more than one beneficiary and want your beneficiaries to
receive equal shares.
You must submit birth date evidence for your named beneficiaries. If your
beneficiary is your spouse and there is a Survivor Continuance benefit, you
must also submit evidence of marriage. For a list of acceptable documents,
refer to “Supporting Documents” on page 20.
Section 4c – Complete Your Beneficiary Information –
Return of Remaining Contributions
Complete all fields for each beneficiary you name. You can change this
beneficiary designation at any time.
Provide the name, Social Security number or CalPERS ID, birth date,
relationship to you, priority (primary or secondary), and address of the
beneficiary you designate to receive any lump-sum balance of your remaining
member contributions or the balance of your temporary annuity benefit
after your death.
You can name primary and
secondary beneficiaries.
The benefit is paid to your
primary beneficiary (or
beneficiaries) first. If the
primary beneficiary dies,
the benefit will go to your
secondary beneficiary.
We pay equal shares
unless you enter a
percentage for each
beneficiary. If you enter
a percentage, the total
must equal 100 percent.
14 888 CalPERS (or 888-225-7377)
Your beneficiary can be:
Any person regardless of their relationship to you. You cannot
designate a guardian to receive benefits for another person.
A class of next-of-kin as a group. For example, you can list your
grandchildren” or “siblings” instead of writing out individual names.
A corporation that is registered in any state with the Secretary of State.
Your estate. CalPERS can only pay to your estate if it is probated.
Your trust. Provide the title and date of your trust, and the name and
address of the person who has a copy of the document. Do not name
the trustee.
If you want to name more than four beneficiaries or you want to name separate
beneficiaries for your Return of Remaining Contributions and temporary
annuity balance, call us toll free at 888 CalPERS (or 888-225-7377). There
is no limit to the number of beneficiaries you can name. You can also change
your lump-sum beneficiary designation any time at my.calpers.ca.gov.
A change in your marital status, domestic partner status, or the birth or
adoption of a child after retirement automatically revokes your original
beneficiary designation.
Note: If you designate a minor child as your beneficiary and the child is still
a minor when the benefit becomes payable, their surviving parent can claim
the child’s death benefit without a court order if the child is in their care.
Or, if the child is not in the custody of their parent we will request a court
order that either appoints someone as guardian of the child’s estate or directs
us to pay the child’s benefit to a blocked bank account. As an alternative to
these methods, you may download a California Uniform Transfers to Minors
Act form that you can complete now to nominate a custodian to claim any
benefits that may become payable to your minor child. Please do not name
the guardian or custodian of a minor child as your beneficiary; just name
the child if that is your desire.
Section 5 – Retired Death Benefit – Beneficiary Designation
The lump-sum Retired Death Benefit is payable upon your death, in addition
to any payment under the option you select. You can select anyone you wish
to receive this benefit. The amount payable is based on your employers
contract with CalPERS.
For state, California State University, or University of California
members, the Retired Death Benefit is $2,000.
For school members, it is $2,000, unless your employer has elected
a higher amount up to $5,000.
For public agency members, the Retired Death Benefit is based
on the employers contract, and it can range from $500 to $5,000.
If you last worked
with another California
retirement system that
provides a similar death
benefit, the CalPERS
Retired Death Benefit
is not paid.
15www.calpers.ca.gov
If you want to name more than four beneficiaries for the Retired Death Benefit
call us toll free at 888 CalPERS (or 888-225-7377). There is no limit to the
number of beneficiaries you can name. You can also change your lump-sum
beneficiary designation any time at my.calpers.ca.gov.
A change in your marital status, domestic partner status, or the birth or
adoption of a child after retirement automatically revokes your original
beneficiary designation.
Section 6 – Survivor Continuance Information
The Survivor Continuance benefit is payable to all state, school, and public
agency members if the former employer has contracted to provide it and you
have an eligible survivor. Survivor Continuance is an employer-paid monthly
benefit paid to an eligible survivor.
If you are not sure if you are covered by this benefit, check with your personnel
office. Benefits are paid to an eligible survivor in addition to and regardless of
which retirement payment option you elect.
Eligible survivors are:
A spouse who was married to you at least one year prior to your retirement
and continuously until your death; or if none,
A domestic partner in a legally state-recognized partnership that was entered
into at least one year prior to your retirement and continuously until your
death; or if none,
Unmarried children under age 18 or an unmarried disabled child who
became disabled prior to age 18 and whose continuing disability renders
the child incapable of gainful employment; or if none,
An economically dependent parent.
Note: If you have a severely disabled minor or adult child who is not capable
of handling their own financial affairs, you may wish to talk with an attorney
about creating a special needs trust so the successor trustee can claim the child’s
survivor allowance without having to obtain a court order for conservatorship or
guardianship of the disabled child. The special needs trust must be established for
the sole benefit of the disabled child during the child’s lifetime and there cannot
be a provision that allows for assignment of the child’s benefit to someone else.
A copy of the special needs trust should be sent to CalPERS to ensure it can be
honored and then retained in your file for future use. Payments to children stop
at age 18, or upon their marriage, death, or recovery from disability.
The amount of the monthly benefit depends on your Social Security coverage.
If your service credit is not covered by Social Security, the Survivor Continuance
is 50 percent of your Unmodified Allowance, based on actual service with an
employer that provides this benefit. If your service credit is covered by Social
Security, the Survivor Continuance is 25 percent of the Unmodified Allowance.
16 888 CalPERS (or 888-225-7377)
Section 7 – Tax Withholding Election
This section tells CalPERS how you want your tax withholding handled.
To assist you in making this decision, see the “Taxes and Your Service
Retirement” section in this publication or talk with your tax advisor.
You can change your withholding at my.calpers.ca.gov or by completing
another CalPERS Tax Withholding Election form.
You can choose only one federal income tax option and one state
income tax option.
If you do not make an election, or if an invalid election is received,
CalPERS is required by law to withhold taxes as if you are married with
three allowances. If you reside outside of California, your CalPERS
pension income is not subject to California state income tax.
Section 8 – Direct Deposit Information
Direct deposit is optional and can be established at any time before or after retirement.
Complete this section only if you want to set up your direct deposit.
Direct deposit electronically transfers your retirement benefit allowance directly
into your checking or savings account, avoiding the need for you to sign and
deposit your benefit check at your bank. This can reduce the risk of loss,
theft, or forgery; give you immediate and uninterrupted deposits; eliminate
the inconvenience of checks; and provide you with a monthly statement of
itemized deductions.
If you submit direct deposit information with your retirement application,
your direct deposit is typically effective with your first retirement payment.
We transmit funds for direct deposit on the first of each month. Your
financial institution determines when your direct deposit funds are available.
You can establish and maintain your direct deposit online through
myCalPERS at my.calpers.ca.gov. Your financial institution must be a
member of the Automated Clearinghouse Association to accept a direct
deposit from CalPERS.
Section 9 – CalPERS Health Coverage
This section tells CalPERS whether you choose to continue CalPERS health
coverage into retirement. Refer to the CalPERS Health Program Guide for
Basic health plan eligibility, enrollment, and choices.
If you decline health coverage into retirement, you are electing to terminate
your health coverage effective on the first day of the second month following
your separation from employment.
If you are eligible for
Medicare, specific rules
apply for you to continue
your CalPERS health
enrollment. Refer to
the CalPERS Medicare
Enrollment Guide for
additional information.
17www.calpers.ca.gov
If eligible, you may enroll in a CalPERS health plan in the future, such as
during an Open Enrollment period or if you meet special enrollment or late
enrollment exceptions described in the CalPERS Health Program Guide.
Section 10 – Spousal Consent to Beneficiary Designation
You must review and sign this acknowledgment if you are married or in a
registered domestic partnership and you name someone other than your spouse
or domestic partner as a beneficiary to receive an ongoing monthly benefit or
lump-sum benefits that may be payable upon your death. Your signature must
be notarized by a notary public or witnessed by a CalPERS representative.
If your spouse or registered domestic partner consents to your beneficiary
designation, his or her signature must also be notarized by a notary public
or witnessed by a CalPERS representative.
Section 11 – Signatures and Notary or Witness Acknowledgment
This section must be completed or your application will be returned.
Your signature and your spouses or registered domestic partner’s signature
must be notarized by a notary public or witnessed by a CalPERS representative
at any CalPERS Regional Office. If you reside in a foreign country, staff at the
U.S. Consulate may witness your form.
If you are married or in a legally recognized domestic partnership, your current
spouse or domestic partner must sign the application to acknowledge your
election of retirement benefit option unless:
You have elected 100 Percent Beneficiary Option 2 or 100 Percent
Beneficiary Option 2 with Benefit Allowance Increase as your retirement
payment option, and
You have designated your spouse or registered domestic partner as the
beneficiary, and
You have designated him or her as the sole primary beneficiary of any
lump-sum benefits.
Otherwise, you must complete the Justification for Absence of Spouses or
Registered Domestic Partner’s Signature form and submit it to CalPERS before
any retirement benefits can be paid.
If you are single, the justification form is not required. Mark “No” and indicate
“Never Married or in Domestic Partnership,” “Divorced, Annulled, or Domestic
Partnership Terminated,” or “Widowed” in this section.
18 888 CalPERS (or 888-225-7377)
What Happens Next?
After you submit your Service Retirement Election Application, CalPERS will
take the steps necessary for you to retire on the day you have selected. Once
your application is received at our Sacramento Headquarters office, you will
receive an acknowledgment letter letting you know we have begun processing
your request, usually within five to 10 days of receipt of your application.
CalPERS will notify you if we have questions or need more information.
Notification of Retirement Allowance
Before you receive your first retirement benefit check, usually after you have
separated from employment, CalPERS will send you a letter providing you
with the date of your first retirement check, the amount you can expect to
receive, and important income tax information. We also include the employer,
retirement formula, service credit, and final compensation information used to
calculate your retirement benefit. Please review this information for accuracy
and report any discrepancies to us immediately. You may be responsible for
repaying any overpaid benefits retroactive to your retirement date that result
from incorrect information being used in your benefit calculation.
Retirement Payment Schedule
We pay in arrears and your first retirement check is typically paid within
45 days of your retirement date, or within 45 days of when you submit
your application. This means if your retirement date is June 15, your first
retirement check will be paid around August, which includes pay for the
two weeks in June and the entire month of July. After that, we pay on
the first of every month so your first full retirement check is paid on
September 1.
Canceling or Making Changes to Your Retirement Application
By law, you have 30 days from the issuance of your first retirement
benefit check to:
Change your retirement payment option
Change your lifetime beneficiary
Change your retirement date
Cancel your retirement
Adjustments to Your Retirement Benefit
Your retirement benefit is calculated using the payroll and service on
your account as of your retirement date. It is normal for additional payroll,
including sick leave, to come in after weve processed your initial benefit.
This means your First Payment Acknowledgment letter, Account Detail
sheet, and monthly benefit may be lower than what you were expecting until
final payroll shows on your account. Adjustments to your retirement benefit
take up to four months to process and are retroactive to your retirement date.
19www.calpers.ca.gov
Employer Certification
If you are currently employed by a CalPERS-covered agency, your employer
must certify your separation information by submitting it and any updates
online using myCalPERS. Separation information includes your permanent
separation date and any unused sick leave or education leave balances, which
may convert to additional service credit depending on your employers contract
with CalPERS. If your employer submits the information prior to CalPERS
processing your retirement application, we will include the additional service
credit in your initial retirement benefit. Otherwise, we will adjust your account
to reflect a change in service credit at the time your employer submits it.
If you left employment at a CalPERS-covered agency more than four months
before your retirement date, you are not entitled to service credit for any
balance of unused sick leave or educational leave.
Authorized Deduction Payments
Many types of payments can be deducted from your monthly retirement
check, such as credit union shares or payments, retiree association fees, charitable
contributions, etc. To make sure all your current deductions continue after
you retire or add new deductions, you must contact the provider and complete
their authorization request. The provider will then submit the request to
CalPERS for processing.
20 888 CalPERS (or 888-225-7377)
SUPPORTING DOCUMENTS
Birth Date Evidence
The following options provide an ongoing monthly benefit to your named
beneficiary (or beneficiaries):
100 Percent Beneficiary Option 2
100 Percent Beneficiary Option 2 with Benefit Allowance Increase
50 Percent Beneficiary Option 3
50 Percent Beneficiary Option 3 with Benefit Allowance Increase
Flexible Beneficiary Option 4
Court-Ordered Community Property Option 4 / Specific Percentage
or Specific Dollar Amount
If you chose any of the options above, provide a photocopy of one of the
following acceptable documents to validate each beneficiarys date of birth:
Birth certificate or delayed birth certificate
Border crossing card with I-94
Drivers license
Foreign passport with I-94
Naturalization or U.S. passport
Social Security certification
Marriage or Domestic Partnership Evidence
If you have a Survivor Continuance benefit, provide a photocopy of one
of the following acceptable documents:
Marriage certificate
State-recognized certificate of domestic partnership
Note: If you do not have any of the documents listed above, please contact us.
Send Photocopies,
Not Original
Documents
CalPERS cannot return
original documents.
Documents submitted
are eventually destroyed.
Please send photocopies
of documents only. You
may upload documents
through your myCalPERS
account when you apply
for retirement online.
This is a request for an estimate of your potential CalPERS retirement benefit amounts. You must be within one year
of your anticipated retirement date to use this form. You are limited to two estimate requests within a 12-month period.
Retirement Allowance Estimate Request
Your Name (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Birth Date (mm/dd/yyyy) Daytime Phone Alternate Phone
Address
City State ZIP
( ) ( )
Enter the address we
have on file for you.
If you need to update
your address, see the
back of this form
for instructions.
Section 1
Information About You
Section 2
Your Retirement Information
You can only select
one type of retirement
estimate per form.
What is a survivor vs. a
beneficiary? See the back
of this form for details and
a complete description of
the available retirement
payment options.
Choose one type:
c
Service Retirement
c
Disability Retirement
c
Industrial Disability Retirement
My projected retirement date is:
Employer Position Title
To include your unused sick leave and/or educational leave in your estimate, enter the number of hours you’ll
have as of your projected retirement date. See the back of this form for eligibility requirements.
Sick Leave Hours Educational Leave Hours
Will you have an eligible survivor on your projected retirement date?
c
Yes
c
No
How many beneficiaries do you want to include in your estimate?
c
None
c
One (Complete the information in the space provided below.)
Name of Beneficiary Relationship to You Birth Date (mm/dd/yyyy)
c
One or more and with a specific dollar or specific percentage amount to each beneficiary.
(Complete the information in the spaces provided below.)
If you are a member of a defined benefit plan with another California public retirement system and want
us to use your final compensation with the other system in your estimate, complete the information below.
Name of Reciprocal System Estimated Final Compensation Amount
If you want to include temporary annuity in your retirement estimate, select one of the choices below.
c
I became a member prior to January 1, 2002, and elect to receive temporary annuity until
age in the amount of $ per month.
c
I became a member on January 1, 2002, or later and have CalPERS service coordinated with Social
Security. I elect to receive temporary annuity until age in the amount of $
per month.
(62 to 70)
Dollars
(59
1
/
2
or whole age 60 to 68)
Dollars
Date Required (mm/dd/yyyy)
Section 3
Advanced Estimate Scenarios
See the back of this
form for information
regarding the Advanced
Estimate Scenarios.
Birth Date (mm/dd/yyyy) Dollar or Percent of Benefit
Birth Date (mm/dd/yyyy) Dollar or Percent of Benefit
Birth Date (mm/dd/yyyy) Dollar or Percent of Benefit
Birth Date (mm/dd/yyyy) Dollar or Percent of Benefit
Mail to:
CalPERS Retirement Benefit Services Division P.O. Box 942711, Sacramento, California 94229-2711
888 CalPERS (or 888-225-7377)
TTY: (877) 249-7442
PERS-BSD-470 (11/19) Page 1 of 1
Section 1
Information About You
If you are an active CalPERS member, contact your personnel office and ask them to update your mailing address with us.
If you are an inactive CalPERS member, update your address at my.calpers.ca.gov or call us toll free at 888 CalPERS
(or 888-225-7377).
Section 2
Your Retirement Information
Retirement Date - Your retirement date can be no earlier than your last day on payroll. If it has been more than nine months
since you left employment, the date you enter cannot be earlier than the first day of the month you submit this form.
Unused Sick Leave/Educational Leave - Your last employer must contract to provide this benefit, and you must retire within
120 days of leaving employment for any unused sick and/or educational leave to be included in your actual retirement benefit.
What is a survivor? - A survivor receives a monthly benefit regardless of the retirement payment you choose. We only
include this in your retirement estimate if your employer contracts to provide this benefit. A survivor is defined by law as:
a spouse or registered domestic partner who was married or registered to you for at least one year before your service
retirement date and continuously until your death. (For disability or industrial disability retirement, these conditions
must be met on or before the effective date of your disability or industrial disability retirement.)
natural or adopted unmarried children under age 18.
an unmarried child who was disabled prior to age 18 and whose disability continues without interruption until
the disability ends or until marriage.
qualifying financially dependent parents, if none of the above.
What is a beneficiary? - A beneficiary is any person you choose to receive either a one-time lump-sum payment
or ongoing monthly benefit upon your death.
Retirement Options - When you retire, you will choose one of the following retirement options and name a beneficiary.
Unmodified Allowance - Provides the highest monthly allowance paid for life. There is no continuing monthly benefit
to a beneficiary and no return of unused member contributions upon your death.
Return of Remaining Contributions Option 1 - Provides a lump-sum payout of any remaining member contributions
in your account to one or more beneficiaries upon your death.
100 Percent Beneficiary Option 2 - Provides 100 percent of the option portion of your ongoing monthly benefit to your
named beneficiary upon your death. Upon both your deaths a lump-sum payout of any remaining member contributions
in your account will be paid to one or more named secondary beneficiaries.
100 Percent Beneficiary Option 2 with Benefit Allowance Increase - Provides 100 percent of the option portion of
your monthly benefit to your named beneficiary upon your death. If your beneficiary dies before you, or if you have another
qualifying event, your benefit will increase to the Unmodified Allowance.
50 Percent Beneficiary Option 3 - Provides 50 percent of the option portion of your ongoing monthly benefit to your
named beneficiary upon your death. Upon both your deaths, a lump-sum payout of any remaining member contributions
in your account will be paid to one or more named secondary beneficiaries.
50 Percent Beneficiary Option 3 with Benefit Allowance Increase - Provides 50 percent of the option portion of your
ongoing monthly benefit to your named beneficiary upon your death. If your beneficiary dies before you, or you have
another qualifying event, your benefit will increase to the Unmodified Allowance.
Flexible Beneficiary Option 4 - Provides an ongoing monthly benefit of a specific dollar amount or percentage of your
Unmodified Allowance to one or more named beneficiaries upon your death.
Section 3
Advanced Estimate Scenarios
Reciprocity
Enter the name of the other California public retirement system you are a member of.
Enter your highest average annual compensation for any consecutive 12- or 36-month period of employment
with the other retirement system.
To be eligible for full reciprocal benefits, such as final compensation exchange, you must retire concurrently.
Refer to the publication When You Change Retirement Systems (PUB 16) for detailed information.
Temporary Annuity
This benefit is only available for a service retirement.
Enter the amount you want to receive and to what age depending on your CalPERS membership date.
If your membership is on or after January 1, 2002, your temporary annuity amount cannot exceed your estimated Social
Security benefit. This benefit is not free. Refer to the publication Temporary Annuity (PUB 13) for detailed information.
PERS-BSD-470 (11/19)
Please provide your
name as it appears on
your Social Security card.
Section 2
Information About Your Retirement
Last Day on Payroll (mm/dd/yyyy) Your Retirement Date (mm/dd/yyyy)
Employer Full Name
Full Position Title
Temporary Annuity
Choosing to receive a temporary annuity will permanently reduce your retirement benefit. Please refer
to the Temporary Annuity publication (PUB 13) before making this choice.
To elect to receive a temporary annuity payment, select one of the choices below.
c
I became a member prior to January 1, 2002, and elect to receive temporary annuity until
age in the amount of $ per month.
c
I became a member on or after January 1, 2002, and have CalPERS service coordinated
with Social Security. I elect to receive temporary annuity until age in the amount
of $ per month.
Other California Public Retirement Systems
If you are a member of a defined benefit plan with a California public retirement system other than CalPERS,
please complete the following:
Name of Reciprocal System
Last Day of Employment With Reciprocal System (mm/dd/yyyy) Retirement Date With Reciprocal System (mm/dd/yyyy)
Please enter the last day
you were on payroll with a
CalPERS-covered employer.
In the event of your death,
any outstanding temporary
annuity payments will be
paid in a lump sum to a
beneficiary. Complete your
beneficiary information
in Section 4c.
(62 to 70)
Dollars(59½ or whole age 60 to 68)
Your Name (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Address
City State ZIP Country
Birth Date (mm/dd/yyyy) Daytime Phone Alternate Phone
Email Address
Dollars
Section 1
Information About You
Please do not mail or deliver your application to CalPERS more than 120 days before your retirement date.
For detailed instructions on how to complete this form, please refer to the publication Service Retirement Election
Application (PUB 43).
( )
( )
888 CalPERS (or 888-225-7377)
TTY: (877) 249-7442
Page 1 of 10
Service Retirement Election Application
PERS-BSD-369-S (1/20)
Section 3
Select Your Retirement Payment Option
Choose one of the following retirement payment options.
c
Unmodified Allowance
There is no beneficiary designation with this option. Skip to Section 5.
c
Return of Remaining
Contributions Option 1
Complete your beneficiary designation in Section 4c.
c
100 Percent Beneficiary Option 2
Complete your beneficiary designation in Sections 4a and 4c.
c
100 Percent Beneficiary Option 2
with Benefit Allowance Increase
Complete your beneficiary designation in Section 4a.
c
50 Percent Beneficiary Option 3
Complete your beneficiary designation in Sections 4a and 4c.
c
50 Percent Beneficiary Option 3
with Benefit Allowance Increase
Complete your beneficiary designation in Section 4a.
c
Flexible Beneficiary Option 4
Choose one of the options below.
c
Specific Percentage
Complete your beneficiary designation in Section 4b.
c
Specific Dollar Amount
Complete your beneficiary designation in Section 4b.
c
Court-Ordered Community
Property Option 4
Provide your former spouse/partner’s information and choose
one of the options below for your share of the benefit.
Former Spouse/Former Registered Domestic Partner (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
c
Unmodified Allowance
There is no beneficiary designation with this option. Skip to Section 5.
c
Return of Remaining
Contributions Option 1
Complete your beneficiary designation in Section 4c.
c
Specific Percentage
Complete your beneficiary designation in Section 4b.
c
Specific Dollar Amount
Complete your beneficiary designation in Section 4b.
Your retirement payment
option choice becomes
irrevocable 30 days
from the date your first
retirement check is issued
unless you have a future
qualifying event, such as
the death of a beneficiary.
If you are required by a
court order to designate
your nonmember spouse
or partner for an ongoing
monthly benefit, choose
one of the Court-Ordered
Community Property
Option 4 options for your
share of the benefit.
Section 4a
Complete Your Beneficiary Information Ongoing Monthly Benefit
If you chose one of the following options, name one beneficiary to receive the ongoing monthly benefit
upon your death.
100 Percent Beneficiary Option 2
100 Percent Beneficiary Option 2 with Benefit Allowance Increase
50 Percent Beneficiary Option 3
50 Percent Beneficiary Option 3 with Benefit Allowance Increase
Name (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Birth Date (mm/dd/yyyy) Gender Relationship to You
Address
City State ZIP Country
The beneficiary you name
in this section becomes
irrevocable 30 days
from the date your first
retirement check is issued
unless you have a future
qualifying event, such as
the death of a beneficiary.
c
Male
c
Female
c
Nonbinary
Page 2 of 10PERS-BSD-369-S (1/20)
Your Name Social Security Number or CalPERS ID
Put your name and Social
Security number or CalPERS ID
at the top of every page.
Any beneficiary you name
in this section becomes
irrevocable 30 days
from the date your first
retirement check is issued
unless you have a future
qualifying event, such as
the death of a beneficiary.
Complete all fields for each
beneficiary and specify the
percentage or dollar
amount. If you name more
than one beneficiary and
you want your beneficiaries
to receive an equal share
of your benefits, do not
specify a dollar or
percentage of benefit.
Section 4b
Complete Your Beneficiary InformationSpecific Percentage or
Specific Dollar Amount
If you chose one of the following options, name one or more beneficiaries to receive a specific percentage
or dollar amount of your Unmodified Allowance upon your death.
Flexible Beneficiary Option 4/Specific Percentage or Specific Dollar Amount
Court-Ordered Community Property Option 4/Specific Percentage or Specific Dollar Amount
If you want to name more
than four beneficiaries, call
us toll free at 888 CalPERS
(or 888-225-7377).
Name (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Birth Date (mm/dd/yyyy) Gender Relationship to You
Dollar Amount Percent of Benefit
Address
City State ZIP Country
c
Male
c
Female
c
Nonbinary
$ %
Name (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Birth Date (mm/dd/yyyy) Gender Relationship to You
Dollar Amount Percent of Benefit
Address
City State ZIP Country
c
Male
c
Female
c
Nonbinary
$ %
Name (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Birth Date (mm/dd/yyyy) Gender Relationship to You
Dollar Amount Percent of Benefit
Address
City State ZIP Country
c
Male
c
Female
c
Nonbinary
$ %
Name (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Birth Date (mm/dd/yyyy) Gender Relationship to You
Dollar Amount Percent of Benefit
Address
City State ZIP Country
c
Male
c
Female
c
Nonbinary
$ %
Page 3 of 10PERS-BSD-369-S (1/20)
Your Name Social Security Number or CalPERS ID
Put your name and Social
Security number or CalPERS ID
at the top of every page.
Section 4c
Complete Your Beneficiary Information Return of Remaining Contributions
If you want to name
separate beneficiaries
for the balance of your
remaining contributions
and/or temporary annuity
balance, call us toll
free at 888 CalPERS
(or 888-225-7377).
If you name more than
one beneficiary and you
want your beneficiaries to
receive an equal share of
your benefits, do not
specify a percentage
of benefit.
If you want to name more
than four beneficiaries, call
us toll free at 888 CalPERS
(or 888-225-7377).
If you chose one of the following options, name one or more beneficiaries to receive a return of any
of your remaining member contributions. You can change this beneficiary designation at any time.
Return of Remaining Contributions Option 1
100 Percent Beneficiary Option 2
50 Percent Beneficiary Option 3
Temporary Annuity (remaining balance upon your death)
Court-Ordered Community Property Option 4/Return of Remaining Contributions Option 1
Name (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Birth Date (mm/dd/yyyy) Relationship to You Priority Percent of Benefit
Address
City State ZIP Country
c
Primary
c
Secondary
Name (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Birth Date (mm/dd/yyyy) Relationship to You Priority Percent of Benefit
Address
City State ZIP Country
Name (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Birth Date (mm/dd/yyyy) Relationship to You Priority Percent of Benefit
Address
City State ZIP Country
Name (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Birth Date (mm/dd/yyyy) Relationship to You Priority Percent of Benefit
Address
City State ZIP Country
c
Primary
c
Secondary
c
Primary
c
Secondary
c
Primary
c
Secondary
%
%
%
%
Page 4 of 10PERS-BSD-369-S (1/20)
Your Name Social Security Number or CalPERS ID
Put your name and Social
Security number or CalPERS ID
at the top of every page.
Section 5
Retired Death Benefit Beneficiary Designation
Name one or more beneficiaries to receive the Retired Death Benefit upon your death. The amount payable
is based on your employer's contract with us. You can change this beneficiary designation at any time.
If you name more than
one beneficiary and you
want your beneficiaries to
receive an equal share of
your benefits, do not
specify a percentage
of benefit.
If you last worked with
another California retirement
system that provides a
similar death benefit, the
CalPERS Retired Death
Benefit is not paid.
If you want to name more
than four beneficiaries, call
us toll free at 888 CalPERS
(or 888-225-7377).
Name (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Birth Date (mm/dd/yyyy) Relationship to You Priority Percent of Benefit
Address
City State ZIP Country
c
Primary
c
Secondary
%
Name (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Birth Date (mm/dd/yyyy) Relationship to You Priority Percent of Benefit
Address
City State ZIP Country
c
Primary
c
Secondary
%
Name (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Birth Date (mm/dd/yyyy) Relationship to You Priority Percent of Benefit
Address
City State ZIP Country
c
Primary
c
Secondary
%
Name (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Birth Date (mm/dd/yyyy) Relationship to You Priority Percent of Benefit
Address
City State ZIP Country
c
Primary
c
Secondary
%
Page 5 of 10PERS-BSD-369-S (1/20)
Your Name Social Security Number or CalPERS ID
Put your name and Social
Security number or CalPERS ID
at the top of every page.
Section 6
Survivor Continuance Information
1. Were you married or in a registered domestic partnership at least one year prior to your retirement date?
c
No
c
Yes, provide:
Name of Spouse/Registered Domestic Partner (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Birth Date (mm/dd/yyyy) Date of Marriage or Registered Domestic Partnership (mm/dd/yyyy)
Address
City State ZIP Country
2. Do you have any natural or legally adopted unmarried children under age 18?
c
No
c
Yes, provide:
Name of Child (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Birth Date (mm/dd/yyyy)
Address
City State ZIP Country
Name of Child (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Birth Date (mm/dd/yyyy)
Address
City State ZIP Country
3. Do you have any unmarried children who were disabled prior to their 18th birthday and who are still
disabled?
c
No
c
Yes, provide:
Name of Child (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Birth Date (mm/dd/yyyy)
Address
City State ZIP Country
Name of Child (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Birth Date (mm/dd/yyyy)
Address
City State ZIP Country
Section 6 continues on page 7
See Survivor Continuance
instructions in the publication
Service Retirement Election
Application (PUB 43) to
learn about eligibility
requirements for this benefit.
Page 6 of 10PERS-BSD-369-S (1/20)
Your Name Social Security Number or CalPERS ID
Put your name and Social
Security number or CalPERS ID
at the top of every page.
Section 6, continued
Survivor Continuance Information, continued
Dollars
Federal Income Tax information:
c
Do not withhold federal income tax.
c
Withhold federal income tax based on the tax tables for:
c
A married individual with tax withholding allowances.
c
A single individual with tax withholding allowances.
In addition to the amount withheld based on the tax tables, withhold $ per month.
c
A married individual, but withhold at the higher single rate with tax withholding allowances.
State Income Tax information:
c
Do not withhold State of California income tax.
c
Withhold State of California income tax in the amount of $ per month.
c
Withhold State of California income tax based on the tax tables for:
c
A married individual with tax withholding allowances.
c
A single individual with tax withholding allowances.
c
A head of household individual with tax withholding allowances.
In addition to the amount withheld based on the tax tables, withhold $ per month.
c
Withhold State of California income tax in the amount of 10 percent of the federal income tax
withholding amount.
Please choose only one.
Number
Number
Number
Number
Number
Number
Dollars
Dollars
Section 7 Tax Withholding Election
Please choose only one.
State withholding
is optional for
out-of-state residents.
4. Are your parents dependent upon you for one-half of their support?
c
No
c
Yes, provide:
Name of Parent (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Birth Date (mm/dd/yyyy)
Address
City State ZIP Country
Page 7 of 10PERS-BSD-369-S (1/20)
Your Name Social Security Number or CalPERS ID
Put your name and Social
Security number or CalPERS ID
at the top of every page.
Section 8 Direct Deposit Information
Section 9 CalPERS Health Coverage
I certify I am entitled to receive this payment. I authorize my retirement payment to be sent to my financial
institution and deposited to my designated account. I understand CalPERS does not accept a prepaid debit card
as a payment option. I authorize amounts transferred after my death or transmitted in error to be debited from
my account. Additionally, I certify that the funds received are not deposited to an account that is subject to being
transferred to a foreign financial institution.*
If you are currently enrolled in your own right for CalPERS health benefits, you can continue your health
enrollment into retirement with no break in coverage.
If you do not want health coverage, you must cancel retiree health coverage by declining coverage below.
You may be eligible to enroll in health coverage during the next Open Enrollment period.
c
I decline continuation of my CalPERS health coverage into retirement.
Do not complete this
section if you want to
receive your retirement
checks by U.S. mail.
*To comply with NACHA
regulations regarding
international ACH
transactions, CalPERS
will not accept requests
for electronic fund transfers
(EFT) in association with
financial institutions outside
of the territorial jurisdiction
of the United States. (The
territorial jurisdiction of the
United States includes all
50 states, U.S. territories,
U.S. military bases, and
U.S. embassies in foreign
countries.) If your entire
benefit allowance will be
received by a financial
institution outside the
territorial jurisdiction of the
U.S., you will be issued a
paper check in lieu of the EFT.
** Trust Account
You also need to
complete and submit a
Request for Payment of
Monthly Allowance to a
Trust form available at
www.calpers.ca.gov
and a copy of the
Certification of Trust from
your trust document.
c
Checking
c
Savings
c
Joint
c
Trust Account **
Routing Number (nine digits) Account Number
If you are authorizing your payment to your savings account or do not have pre-printed, personalized checks,
please have your financial institution complete the information below.
Please use tape to attach your voided, pre-printed personalized check. (Do not staple or paper clip. No deposit slips.)
Name of Financial Institution Branch Phone Number
Address
City State ZIP
You confirm the identity of the above-named payee and the account number. As a representative of the above-named
financial institution, you certify the financial institution agrees to receive and deposit the payment identified above.
Signature of Representative Print Representative’s Name Date (mm/dd/yyyy)
( )
You can view and print your benefit statement, which shows your total deposit amount, including any
reimbursements or authorized deductions, at my.calpers.ca.gov.
Information About Joint Account Holder, if applicable
Name Social Security Number or CalPERS ID
Address Daytime Phone
City State ZIP
( )
Page 8 of 10PERS-BSD-369-S (1/20)
Your Name Social Security Number or CalPERS ID
Put your name and Social
Security number or CalPERS ID
at the top of every page.
You must review and sign this acknowledgment if you are married or in a registered domestic partnership and
you name someone other than your spouse or domestic partner as a beneficiary to receive an ongoing monthly
benefit or any lump-sum benefits that may be payable upon your death.
Member Acknowledgment
I understand that if I am married or in a registered domestic partnership, my spouse or domestic partner
may have community property rights in one or more of the following benefits (if applicable):
The monthly option benefit that continues following a member’s death;
The return of any remaining member contributions; and/or
The Retired Death Benefit.
If I name someone other than my spouse or domestic partner as my beneficiary for some or all of these benefits
and I die before my spouse or domestic partner, he or she may still be entitled to receive his or her community
property share of the benefit(s). If I name one or more other individuals as my beneficiary(ies) to receive a benefit
listed above, and my spouse or domestic partner does not consent at this time by signing below, CalPERS will
award 50 percent of the community property share of such benefit to my spouse or domestic partner in the
event of my death unless he or she waives his or her community property interest in such benefit at the time the
benefit becomes payable, and CalPERS will award the remaining 50 percent of the community property share,
plus any separate property share, of such benefit to the named beneficiary(ies).
Your Signature Date (mm/dd/yyyy)
Spouse’s or Registered Domestic Partner’s Consent
I hereby voluntarily and irrevocably consent to each of the beneficiary designation(s) by my spouse/registered
domestic partner in this application. I acknowledge and understand that I am not obligated to consent and, if I
do consent, and my spouse or registered domestic partner dies before me and has named a beneficiary other
than me, some or all of the following benefits will be paid to a beneficiary other than me in accordance with the
beneficiary designation(s):
The monthly option benefit that continues following a member’s death;
The return of any remaining member contributions; and/or
The Retired Death Benefit.
I understand that I may have community property or other rights in these benefits, and I hereby voluntarily waive
and release any rights I may have to these benefits. I understand that I do not have to sign this consent and that
if I do sign my consent is irrevocable. I acknowledge that I have received a complete explanation of each benefit
listed above (if applicable), and I have had the opportunity to consult with an attorney or other professional
concerning this waiver.
Your Spouse’s or Domestic Partner’s Signature Date (mm/dd/yyyy)
Section 10 Spousal Consent to Beneficiary Designation
Your signature must be
notarized by a notary public
or witnessed by a
CalPERS representative.
Your spouse or registered
domestic partner should
sign this consent if he or
she consents to each of your
beneficiary designations
after reviewing this section.
His or her signature must be
notarized or witnessed by a
CalPERS representative.
Page 9 of 10PERS-BSD-369-S (1/20)
Your Name Social Security Number or CalPERS ID
Put your name and Social
Security number or CalPERS ID
at the top of every page.
Section 11 Signatures and Notary or Witness Acknowledgment
This section must
be completed or
your application will
be returned.
Your signature and your
spouse’s or registered
domestic partner’s signature
must be notarized by a
notary public or witnessed
by a CalPERS representative.
I certify, under the penalty of perjury, that the information submitted hereon is true and correct to the best of
my knowledge. I understand that I only have 30 days from the issuance of my first retirement benefit
check to cancel or make any changes to this application. If I seek post-retirement CalPERS employment,
I understand I must read the publication A Guide to CalPERS Employment After Retirement (PUB 33), which
contains information about the requirements for such employment.
Are you legally married or do you have a state-recognized registered domestic partner?
F
Yes
F
No
If no, please indicate:
F
Never Married or in Domestic Partnership
F
Divorced, Annulled, or Domestic Partnership Terminated
F
Widowed
If you answered yes above, your spouse or registered domestic partner must sign this application unless you
have elected 100 Percent Beneficiary Option 2 or 100 Percent Beneficiary Option 2 with Benefit Allowance
Increase as your retirement payment option, and you designated your spouse or registered domestic partner
as the beneficiary, and you designated him or her as the sole primary beneficiary of any lump-sum benefits.
Otherwise, you must complete and submit the Justification for Absence of Spouse’s or Registered Domestic
Partner’s Signature form.
Your Signature Date (mm/dd/yyyy)
Your Spouse’s or Domestic Partner’s Signature Date (mm/dd/yyyy)
A notary public or other officer completing this certificate verifies only the identity of the individual who signed
the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.
State of California, County of On
before me, personally appeared
, who proved to me on the basis of satisfactory evidence to be the person(s)
whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed
the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the
person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under Penalty
of Perjury under the laws of the State of California that the foregoing paragraph is true and correct.
Notary Seal
Witness my hand and official seal or authorized CalPERS representative signature.
Signature of Notary or CalPERS Representative Position Title Date (mm/dd/yyyy)
Print Name CalPERS Office (if applicable)
Date
Name of Notary/Witness
Mail to:
CalPERS Retirement Benefit Services Division P.O. Box 942711, Sacramento, California 94229-2711
PERS-BSD-369-S (1/20) Page 10 of 10
Your Name Social Security Number or CalPERS ID
Put your name and Social
Security number or CalPERS ID
at the top of every page.
Section 1
Member Information
Name of Member (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Pursuant to Government Code section 21261, an election of optional settlement, designation of beneficiary, or
change in beneficiary shall contain the signature of the current spouse or registered domestic partner unless the
retirement payment option provides him or her 100 percent of the member’s monthly allowance and he or she was
also named as the sole beneficiary for any lump-sum benefits.
If a spouse’s or registered domestic partner’s signature is required and he or she is unable to sign
the retirement application or beneficiary designation form, the following information must be completed
by the member.
By checking this box, I indicate that I am married or have a registered domestic partner, but my spouse
or registered domestic partner did not sign this form because:
I do not know and have taken all reasonable steps to determine the whereabouts of my spouse
or registered domestic partner; or
My spouse or registered domestic partner has been advised of the application and has refused
to sign the written acknowledgment; or
My spouse or registered domestic partner is incapable of executing the acknowledgment because
of an incapacitating mental or physical condition; or
My spouse or registered domestic partner has no identifiable community property interest
in the benefit; or
My spouse or registered domestic partner and I have executed a marriage settlement or partnership
agreement that makes the community property law inapplicable to the marriage or partnership.
Mail to:
CalPERS Retirement Benefit Services Division P.O. Box 942711, Sacramento, California 94229-2711
Section 2
Information Certification
I certify under penalty of perjury that the foregoing information is true and correct.
Signature of Member Date (mm/dd/yyyy)
888 CalPERS (or 888-225-7377)
TTY: (877) 249-7442
Justification for Absence of Spouse’s
or Registered Domestic Partner’s Signature
PERS-BSD-800A (12/19) Page 1 of 1
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35www.calpers.ca.gov
C alPERS HEALTH BENEFITS
Health Insurance Covered Under PEMHCA
If you are nearing retirement, read this section to gain an understanding of
how retirement will affect your health benefits under the Public Employees
Medical and Hospital Care Act (PEMHCA). Contact your health benefits
officer or personnel office for questions about your health benefits. Once you
are retired, contact CalPERS for any questions about your health benefits or
to make changes to your plan or dependents.
You can obtain health benefits publications, required forms, and other
information about your CalPERS health benefits through our website
at www.calpers.ca.gov or by calling CalPERS at 888 CalPERS
(or 888-225-7377).
Our Health Program Guide describes CalPERS Basic health plan eligibility,
enrollment, and choices. It provides an overview of CalPERS health plan
types and tells you how and when you can make changes to your plan
(including what forms and documentation you will need). It also describes
how life changes or changes in your employment status can affect your
benefits and eligibility.
Our annual Health Benefit Summary provides valuable information to help
you make an informed choice about your health plan and compare benefits,
covered services, and co-payment information for all CalPERS health plans.
Our Medicare Enrollment Guide provides information about how Medicare
works with your CalPERS health benefits.
Your Separation Date and Your Retirement Date
As retirement approaches, two dates are particularly important: your
separation date (last day of employment) and your retirement date. If you
are not sure when these dates occur, talk to your employer. Below are your
health plan enrollment options when you retire.
If your separation date and your retirement date are within 30 days of
each other and you are enrolled in a CalPERS health plan at the time of
retirement, your coverage will continue into retirement without a break.
If you do not want your health benefits to continue into retirement, you
have the option to cancel your coverage by:
Submitting a Health Benefits Plan Enrollment form to your employer
(if you are still employed),
Declining health coverage in the CalPERS Service Retirement Election
Application, or
Writing or calling CalPERS to request to cancel health coverage
(if you are already retired).
Important!
If you are currently a
member of the CalPERS
Health Program, you
must meet specific
requirements to continue
your health insurance
coverage into retirement
or to maintain the right
to re-enroll in the future
after retirement.
Once you retire,
CalPERS becomes your
health benefits officer.
This means you can
make most changes to
your health enrollment
by calling CalPERS
at 888 CalPERS
(or 888-225-7377) or
log in to your personal
myCalPERS account
at my.calpers.ca.gov.
36 888 CalPERS (or 888-225-7377)
If your separation date and your retirement date are between 31 and
120 days of each other, and you are enrolled in a CalPERS health plan at
separation, your coverage will not automatically continue. You may re-enroll by:
Writing to CalPERS within 60 days of your retirement date and requesting
re-enrollment, or
Waiting for the next Open Enrollment period.
You can pay monthly premiums directly to your health plan when you are not
on a regular pay status. And you can avoid having your coverage suspended
between your last day of work and your retirement date by paying the full
monthly premium. Contact the health benefits officer where you worked and
complete a Direct Payment Authorization form within 30 days of your last day
on pay status.
If you are eligible for CalPERS health benefits, but are not enrolled in a
health plan at retirement and your retirement date is within 120 days of
separation, you may enroll within 60 days of retirement or during a future
Open Enrollment period. Contact CalPERS for more information and
assistance with your enrollment.
If your retirement effective date is more than 120 days after separation from
employment, you are not eligible for coverage at retirement or at any future
date. There are some exceptions to this rule. Contact CalPERS if you have
questions about your eligibility.
If you were covered as a dependent through another health plan when
you retired, or you canceled coverage to participate in the state’s FlexElect
Program, you may be eligible to enroll in a CalPERS health plan. Contact
CalPERS for more information.
If you have questions about your CalPERS health benefits and you are an
active member, contact your personnel office or health benefits officer. If you
are a retiree, contact CalPERS.
Medicare
Medicare is a federal health insurance program for individuals:
Age 65 or older
Under age 65 with certain Social Security-qualified disabilities
With end-stage renal disease
Medicare is managed by the Centers for Medicare and Medicaid Services
(CMS). The Social Security Administration (SSA) works with CMS to
determine eligibility and to enroll individuals in Medicare.
37www.calpers.ca.gov
Medicare consists of different parts:
Part A (Hospital Insurance)
Part B (Medical Insurance)
Part C (Medicare Advantage Plans)
Part D (Prescription Drug Coverage)
If you and/or your dependent are 65 or older, retired, enrolled in a CalPERS
Basic health plan, and become Medicare eligible, you must enroll in Medicare
Part A and Part B and transfer to a CalPERS Medicare health plan to continue
CalPERS health coverage.
If you do not qualify for premium-free Part A based on your Social Security/
Medicare work record or the record of your current, former, or deceased spouse,
you must provide supporting documentation from the SSA that you are not
eligible for premium-free Part A to remain enrolled in a CalPERS Basic health
plan. If you later qualify for Part A at no cost, you must enroll in Part A and
Part B, provide your Medicare information to CalPERS, and then transfer to
a CalPERS Medicare health plan.
If you are under age 65 and are Medicare eligible, you must provide your
Medicare information to CalPERS and then transfer to a CalPERS Medicare
health plan.
Although Part A may be at no cost to qualifying individuals, the SSA establishes
a standard Part B premium. The monthly Part B premium must be paid to the
SSA to remain enrolled in Part B. If your income exceeds established thresholds,
the SSA will increase your Part B premium by an income-related monthly
adjustment amount. Payment of the Part B premium is mandatory to protect
your eligibility to remain enrolled in a CalPERS Medicare health plan. If you
voluntarily terminate your enrollment in Part B, your CalPERS health coverage
will be canceled.
CalPERS offers Medicare Advantage plans that include Part A, Part B, and
Part D. You must remain enrolled in Part A, Part B, and Part D to continue
your enrollment in a Medicare Advantage plan. If you voluntarily terminate
your Medicare coverage, you will be disenrolled from the Medicare Advantage
plan and canceled from CalPERS health coverage.
CalPERS participates in a Medicare Part D prescription drug plan. If you
are a Medicare-eligible subscriber or dependent, you are automatically enrolled
into an Employer Group Waiver Plan (EGWP). If you are enrolled in a Preferred
Provider Organization (PPO) Supplement to Medicare plan, you may choose
to opt out of the Part D prescription drug coverage; however, you will be
financially responsible for all of your prescription drug costs. If you enroll
in a non-CalPERS Medicare Part D plan, you are no longer eligible to remain
enrolled in a CalPERS Medicare health plan. Consequently, you and all of
your covered dependents will be canceled from CalPERS health coverage.
38 888 CalPERS (or 888-225-7377)
Medicare Part D standard premiums are paid to your health carrier as part
of the CalPERS health premium. As with Medicare Part B, if your income
exceeds established thresholds, the SSA will assess an additional income-related
monthly adjustment amount. This amount must be paid to the SSA to protect
your Medicare enrollment and eligibility to remain enrolled in a CalPERS
Medicare health plan. If you do not pay the additional amount, you will
be disenrolled from EGWP and be financially responsible for all of your
prescription drug costs.
CalPERS offers several Medicare health plans. See the CalPERS Medicare
Enrollment Guide for more detailed information or visit our website at
www.calpers.ca.gov.
For information about the Medicare program, call Medicare at (800) 633-4227
or TTY (877) 486-2048, or visit their website at www.medicare.gov.
For information regarding Medicare eligibility and enrollment, or Medicare
premiums, call the SSA at (800) 772-1213 or TTY (800) 325-0778 or visit
their website at www.ssa.gov.
Dental Coverage and Vesting Requirements
(State and CSU Members Only)
State of California and California State University (CSU) employees receiving
a retirement allowance from CalPERS who retire within 120 days of separation
from employment are eligible for dental benefits.
Continuation of your dental coverage into retirement is not automatic.
Your personnel office must complete a new Dental Plan Enrollment
Authorization form and process your dental enrollment upon your separation
from employment. If you are not enrolled at the time of retirement, you can
enroll during Open Enrollment. Open Enrollment is held each fall and changes
become effective the following January 1.
When you retire, the state may contribute toward the cost of your dental
benefits based on the date you were first hired, your bargaining unit at
retirement, and your years of service. The date you were first hired means the
date you were employed with the State of California for the first time. If that
employment did not qualify you for CalPERS membership or you withdrew
contributions for that period, it is still considered your first-hired date. If you
were first hired by the State of California on or after July 1, 1998, you could
be subject to dental vesting requirements. To determine if your bargaining unit
has agreed to these requirements, contact the California Department of Human
Resources (CalHR). If you were first hired by the CSU system on or after
July 1, 2017, you could be subject to dental vesting requirements. To determine
if your bargaining unit has agreed to these requirements, contact the CSU
Chancellor’s Office.
39www.calpers.ca.gov
Vision Care (State and CSU Members Only)
As a State of California or CSU retiree, you are eligible to enroll in the State
Retiree Vision Program, which is offered through Vision Service Plan (VSP).
This program provides vision coverage for you and your eligible dependents
at your cost.
CalHR and the CSU Chancellor’s Office coordinate the program through
VSP. For more information and to obtain enrollment forms, visit the VSP
website at www.vsp.com. You may also call VSP directly at (800) 877-7195.
Long-Term Care
If you are enrolled in CalPERS Long-Term Care and have premiums
deducted from your paycheck, you will need to call the programs customer
service center toll free at (800) 982-1775 before you retire to find out what
steps are needed to continue your premium deductions after retirement.
40 888 CalPERS (or 888-225-7377)
TAXES AND YOUR SERVICE RETIREMENT
The following information is designed to help you understand and calculate
the tax responsibilities of your CalPERS service retirement allowance.
As a CalPERS retiree, you may still have to pay both federal and state income
taxes. Just like in your working years, you must fill out a tax withholding form.
While CalPERS can provide you with information on some tax laws, you
should request more information on the taxability of your retirement allowance
from the Internal Revenue Service, California Franchise Tax Board, or from
your tax advisor.
1099-R Annual Tax Reporting Statement
Each January, you will receive a 1099-R form containing information on your
CalPERS income from the previous calendar year. Box 1 on the 1099-R form,
labeled “Gross Distribution,” contains the total amount of your gross allowance.
This is normally the accumulated annual gross amount of the payments you
received dated January 1 through December 31. Box 2a, labeled “Taxable
Amount,” contains the amount of your gross allowance that is taxable income.
This is the amount that you will report as income on your personal income
tax return. Box 5, labeled “Employee Contributions or Insurance Premiums,”
contains the amount of tax-free contributions you may have, if any.
CalPERS participates in the Combined Federal/State Filing Program. This
means the California Franchise Tax Board or your state of residence may
access your reported income.
Calculating the Monthly Tax-Free Portion of Your
Retirement Allowance
Federal law requires CalPERS to use certain methods to calculate and report
the annual tax-free portion of your retirement allowance. The tax-free portion
is determined based on the previously taxed contributions you may have
made when you were working. At different times during your work years,
some contributions may have been deducted before taxes and some after
taxes. The total amount may be found on your First Payment Acknowledgment
letter under the heading of “Income Tax Information.”
CalPERS uses the Simplified Method tables in Internal Revenue Service
(IRS) Publication 575 to determine the tax-free portion of your allowance.
For retirements effective on or after January 1, 1998, use one of the following
tables to determine the number of your lifetime payments. Divide the amount
of your “Taxed Contributions” by the “Number of Lifetime Payments” to get
your monthly tax-free allowance amount.
41www.calpers.ca.gov
Note: If you were age 75 or over on your retirement effective date, you
cannot use these tables. Instead, the IRS requires you to use the “General
Rule” to determine your monthly/annual tax-free portion. Information on
the “General Rule” can be found in IRS Publication 939, available on the
IRS website at www.irs.gov or by calling the IRS at (800) 829-1040.
Table 1 – Simplified Method, Single Life Annuity
Unmodified Allowance or Return of Remaining Contributions Option 1
Find your age at retirement and use the corresponding
payment numbers.
Age at Retirement
Number of
Lifetime Payments
55 or under 360
56-60 310
61-65 260
66-70 210
71-74 160
Table 2 – Simplified Method, Joint Life Annuity Retirement
Retirement Options That Provide an Ongoing Lifetime Benefit
Find your and your beneficiary’s combined ages at
retirement and use the corresponding payment numbers.
Combined Ages of Annuitants
at Retirement*
Number of
Lifetime Payments
110 or under 410
111- 12 0 360
121-130 310
131-140 260
141 or over 210
* If you elected an ongoing lifetime benefit and have more than one beneficiary designated
to receive a lifetime benefit, you must use the youngest beneficiarys age along with your
age at retirement to determine the combined ages of annuitants at retirement.
42 888 CalPERS (or 888-225-7377)
Federal Tax Considerations
You may be penalized by the IRS if you do not withhold a sufficient amount
during the tax year. To avoid any penalties, contact your local IRS office or a
tax advisor to ensure you comply with federal tax withholding rules.
For more information about federal taxes, contact your local IRS office or
a tax advisor. You can obtain a free copy of Pension and Annuity Income,
IRS Publication 575, by calling toll free (800) 829-1040 or by visiting their
website at www.irs.gov.
California State Taxes
Since federal legislation prohibits states from taxing the pension income of
non-residents, if you reside outside the state, California state taxes will not be
withheld from your CalPERS benefit without your authorization. While your
CalPERS benefit is still a California source income, there is no longer any
California source tax for qualified non-residents. If you have questions about
your California residency status or your California state taxes, contact the
California Franchise Tax Board (or visit their website at www.ftb.ca.gov)
or contact a tax advisor.
Tax Withholding Election
Unless you submit an election for tax withholding, CalPERS is required to
withhold taxes from your monthly allowance based on the tax tables for a
married person with three allowances. By law, all CalPERS retirees whose
allowances are taxable are required to select one of the three withholding choices:
To have no taxes withheld;
To have a specific dollar amount withheld (state withholding only); or
To have taxes withheld according to the tax tables, based on marital status
and number of allowances (you may also add a specific dollar amount
to this election).
If you choose one of the tax tables, taxes will not be withheld unless your
gross allowance exceeds the minimum amount listed on the tax table for
your filing status (i.e., single, married, number of dependents, etc.).
43www.calpers.ca.gov
BECOME A MORE INFORMED MEMBER
CalPERS Website
Visit www.calpers.ca.gov for information on all our benefits and services.
You can also sign up to receive email newsletters and alerts.
myCalPERS
Log in at my.calpers.ca.gov to access real-time details and balances of your
CalPERS accounts. With myCalPERS you can:
View, print, and save current and past statements.
Select mailing preferences for your statements, newsletters, and retirement checks.
Search for medical premium rates and health plans available in your area
and confirm which dependents are covered on your health plan.
Estimate your future retirement benefit and save estimates to view later.
Send and receive secure messages.
Order and download publications.
Send account information to third parties, such as banks.
Apply for service retirement.
Change your beneficiary designation.
View the status of your service credit request, elected service credit details,
and payoff information.
Retirees can update contact information, set up direct deposit, change tax
withholdings, and view annual tax statements.
CalPERS Education Center
Whether youre in the early stages of your career or getting ready to retire,
visit the CalPERS Education Center in myCalPERS to:
Take online classes to help you understand your benefits.
Register for instructor-led classes and download class materials.
Register to attend a CalPERS Benefits Education Event at a location near you.
Schedule a one-on-one appointment at your nearest CalPERS Regional Office.
Experience CalPERS Through Social Media
Facebook: www.facebook.com/myCalPERS
Twitter: www.twitter.com/CalPERS
Instagram: www.instagram.com/CalPERS
YouTube: www.youtube.com/CalPERS
LinkedIn: www.linkedin.com/company/CalPERS
Reach Us by Phone
Call us toll free at 888 CalPERS (or 888-225-7377).
Monday through Friday, 8:00 a.m. to 5:00 p.m.
TTY: (877) 249-7442
44 888 CalPERS (or 888-225-7377)
Visit Your Nearest CalPERS Regional Office
Fresno Regional Office
10 River Park Place East, Suite 230
Fresno, CA 93720
Glendale Regional Office
Glendale Plaza
655 North Central Avenue, Suite 1400
Glendale, CA 91203
Orange Regional Office
500 North State College Boulevard, Suite 750
Orange, CA 92868
Sacramento Regional Office
Lincoln Plaza East
400 Q Street, Room 1820
Sacramento, CA 95811
San Bernardino Regional Office
650 East Hospitality Lane, Suite 330
San Bernardino, CA 92408
San Diego Regional Office
7676 Hazard Center Drive, Suite 350
San Diego, CA 92108
San Jose Regional Office
181 Metro Drive, Suite 520
San Jose, CA 95110
Walnut Creek Regional Office
Pacific Plaza
1340 Treat Boulevard, Suite 200
Walnut Creek, CA 94597
Visit the CalPERS website for directions to your local office.
Regional Office hours are Monday through Friday, 8:00 a.m. to 5:00 p.m.
45www.calpers.ca.gov
Important Information for Regional Office Visits
Prior to your office visit, please ensure the following important steps are
completed:
Complete all forms in the application publication to the best of your ability.
Review the estimate of retirement benefits and bring the estimate with you
to this appointment.
Bring your picture identification.
Your spouse or legal partner must also attend the appointment and bring
his/her picture identification.
If applicable, bring copies of your marriage or domestic partner certificate.
Bring a copy of your beneficiarys birth certificate.
Write down any questions you have in advance.
What We Can Do
Answer basic retirement-related questions.
Receive and witness completed retirement applications.
Accept CalPERS forms and supporting documents.
Receive requests for retirement estimates to be mailed to your home.
Register you for a free member education class or individual appointment.
What We Cannot Do During Your Visit
Conduct detailed research on your account.
Resolve complex account issues or discrepancies.
Provide immediate retirement estimate results.
46 888 CalPERS (or 888-225-7377)
PRIVACY NOTICE
The privacy of personal information is of the utmost importance to
CalPERS. The following information is provided to you in compliance with
the Information Practices Act of 1977 and the Federal Privacy Act of 1974.
Information Purpose
The information requested is collected pursuant to the Government Code
(sections 20000 et seq.) and will be used for administration of Board duties
under the Retirement Law, the Social Security Act, and the Public Employees
Medical and Hospital Care Act, as the case may be. Submission of the requested
information is mandatory. Failure to comply may result in CalPERS being
unable to perform its functions regarding your status. Please do not include
information that is not requested.
Social Security Numbers
Social Security numbers are collected on a mandatory and voluntary basis.
If this is CalPERS’ first request for disclosure of your Social Security number,
then disclosure is mandatory. If your Social Security number has already been
provided, disclosure is voluntary. Due to the use of Social Security numbers by
other agencies for identification purposes, we may be unable to verify eligibility
for benefits without the number.
Social Security numbers are used for the following purposes:
1. Enrollee identification
2. Payroll deduction/state contributions
3. Billing of contracting agencies for employee/employer contributions
4. Reports to CalPERS and other state agencies
5. Coordination of benefits among carriers
6. Resolving member appeals, complaints, or grievances with health plan carriers
Information Disclosure
Portions of this information may be transferred to other state agencies (such as
your employer), physicians, and insurance carriers, but only in strict accordance
with current statutes regarding confidentiality.
Your Rights
You have the right to review your membership files maintained by the System.
For questions about this notice, our Privacy Policy, or your rights, please write
to the CalPERS Privacy Officer at 400 Q Street, Sacramento, CA 95811 or
call us at 888 CalPERS (or 888-225-7377).
CalPERS is governed by the Public Employees’ Retirement Law and the Alternate
Retirement Program provisions in the Government Code, together referred to as the
Retirement Law. The statements in this publication are general. The Retirement
Law is complex and subject to change. If there is a conflict between the law and this
publication, any decisions will be based on the law and not this publication. If you
have a question that is not answered by this general description, you may make a
written request for advice regarding your specific situation directly to the CalPERS
Privacy Officer at 400 Q Street, Sacramento, CA 95811.
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2020.1.1
California Public Employees’ Retirement System
400 Q Street
P.O. Box 942701
Sacramento, California 94229-2701
888 CalPERS (or 888-225-7377)
PUB 43
January 2020