RETIREMENT BOARD | EMPLOYEE RETIREMENT SYSTEM
Providence City Hall | 25 Dorrance Street, Room 409, Providence, Rhode Island 02903
401 421 7740 ph | 401 453 6175 fax
www.providenceri.com
APPLICATION FOR SERVICE RETIREMENT
MEMBER INFORMATION
Name_____________________________________ SSN___________________________
Address___________________________________ Date of Birth_____________________
City_________________________ State_________ ZIP____________________________
Phone _____________________________________ Retirement Date _________________
To the Providence Retirement Board,
I, _________________________________, the undersigned member of the Employee
Retirement System of the City of Providence, in accordance with Chapter 429, of the State of Rhode Island
and Providence Plantations, as amended, do hereby apply for retirement from active service as a
_______________________________________ in _____________________________.
Give title of position as it appears on the payroll Give department in which employed
Signature_______________________________ Date___________________________
BENEFICIARY INFORMATION
Name_____________________________________ Relationship________________________
Date of Birth _______________________________ SSN______________________________
Address_________________________ City__________________ State ______ ZIP_________
NOTARIZATION OF MEMBER’S OR REPRESENTATIVE’S SIGNATURE
State of _______________________, County of ___________________________
Subscribed and sworn to (or affirmed) before me on this the __________ day of
________________, _________________.
(Seal)__________________________ ___________________________________________
Date of Commission Expiration Notary Public
