Rev. 3/11
Date
Date
Member's Age:
Date: Date:
4. Address:
8. Phone Number:7. Zip:6. State:5. City:
11. Position:
Basic Benefit Level Payment
14. DROP Exit Date:13. DROP Entry Date:
20. Address:
19. Birth Date:
1st Reviewer: 2nd Reviewer:
Board of Trustees Agenda Date:
Average Final Compensation:
RRS Use Only
3. Birth Date:
12. Membership Plan: Defined Benefit Plan Defined Benefit Plan with Enhanced Option
PART C: PAYMENT OPTIONS (Refer to the Public Safety Member's Handbook)
PART B: TYPE OF RETIREMENT (Refer to the Public Safety Member's Handbook)
16. Benefit Payment Option
(Check One)
15. Type of Retirement (Check One)
Service (Normal Retirement - Age 60 or older) Early Service (Age & Service) Early Service (Service)
Notary Public
Member's Signature
18. SSN:
PART E: MEMBER'S CERTIFICATION
I hereby certify that: 1) all of the foregoing facts are correct, 2) I have read and understand the service retirement information in the Members Handbook, 3) I have
read and understand the DROP Administrative Guidelines, 4) I have satisfied the retirement eligibility requirements set forth in the City of Richmond Code Chapter
78 and 5) I fully understand Section 78-208 of the City of Richmond Code governing the DROP and Article IX of Chapter 78 of the City of Richmond Code
governing payment options available to me. I further understand that I must: 1) submit proof of my birth date, 2) submit proof of my beneficiary's birth date, if I
elect a survivorship option, 3) make an election to retain all or part of my unused sick leave upon entry into the DROP, and 4) complete additional payroll forms
upon exiting DROP. Additionally, I understand that I am considered a retired member for all purposes related to the System and I agree that I or my estate will
repay any excess payment of benefits, if any, to which I was not entitled.
17. Name:
Member's Creditable Service:
To be completed by notary or other court official authorized to take acknowledgements:
State of______________________ City/County of __________________________ on __________________ 20 _____
The individual whose name is signed above appeared before me, acknowledged the signature
to be his/her, and having been duly sworn by me, made an oath that the statements are true.
21. Relationship: Spouse Other
PART D: SURVIVOR INFORMATION (Complete Part D only if you chose a survivorship option in Part C.)
My commission expires: __________ Notary Registration No.: ___________
10. Department:
DEFERRED RETIREMENT OPTION PROGRAM (DROP)
RETIREMENT APPLICATION
please type or print in ink
2. SSN:1. Name:
_____% Pop-Up Joint and Last Survivorship
PART A: MEMBER INFORMATION
_____% Joint and Last Survivorship
Smooth-Out
9. Email Address:
900 East Broad Street
Room 400
Richmond, VA 23219
RICHMOND RETIREMENT SYSTEM
www.richmondgov.com/retirement
Phone 804.646.5958
Fax 804.646.5299
