Florida Retirement System Pension Plan
Spousal Acknowledgment Form
PO BOX 9000 Tallahassee, FL 32315-9000
Local Phone: 850-907-6500 Toll Free: 844-377-1888 FAX: 850-410-2010
SA-1
Rev. 01/10
Calculations
Rule 60S-4.010, F.A.C.
Page 1 of 1
CHECK ONE OF THE FOLLOWING:
MARRIED:
YES NO IF YES AND YOU SELECTED OPTION 1 OR 2,
YOUR SPOUSE MUST ALSO COMPLETE BOX 2.
Notarized Signature of Member:
Notary: State of Florida, County of
. The above named person who has sworn to and
subscribed before me this day of 20 and is personally known or
produced as identification.
Signature of Notary Public - State of Florida
Print, Type or Stamp Commissioned Name of Notary Public
1
SPOUSAL ACKNOWLEDGMENT: I, being the spouse of the above named
member, acknowledge that the member has selected either Option 1 or 2.
Notarized Signature of Spouse:
Notary: State of Florida, County of
. The above named person who has sworn to and
subscribed before me this day of 20 and is personally known or
produced as identification.
Signature of Notary Public - State of Florida
Print, Type or Stamp Commissioned Name of Notary Public
The following is an explanation of all four Florida Retirement System Options:
Option 1: A monthly benefit payable for my lifetime. Upon my death, the monthly benefit will stop and my beneficiary will
receive only a refund of any contributions I have paid which are in excess of the amount I have received in benefits.
This option does not provide a continuing benefit to my beneficiary.
Option 2: A reduced monthly benefit payable for my lifetime. If I die within a period of ten years after my retirement date, my
designated beneficiary will receive a monthly benefit in the same amount as I was receiving for the balance of the
10-year period. No further benefits are then payable.
Option 3: A reduced monthly benefit payable for my lifetime. Upon my death, my joint annuitant, if living, will receive a lifetime
monthly benefit payable in the same amount as I was receiving. (Exception: The benefit paid to a joint annuitant
under age 25, who is not your spouse, will be your option one benefit amount. The benefit will stop when your joint
annuitant reaches age 25, unless disabled and incapable of self-support, in which case the benefit will continue for
the duration of the disability.) No further benefits are payable after both my joint annuitant and I are deceased.
Option 4: An adjusted monthly benefit payable to me while both my joint annuitant and I are living. Upon the death of either my
joint annuitant or me, the monthly benefit payable to the survivor is reduced to two-thirds of the monthly benefit
received when both were living. (Exception: The benefit paid to the joint annuitant under age 25, who is not your
spouse, will be your option one benefit amount. The benefit will stop when your joint annuitant reaches age 25,
unless disabled and incapable of self-support, in which case the benefit will continue for the duration of the
disability.) No further benefits are payable after both my joint annuitant and I are deceased.
2
Member Name: Member SSN:
