The Choice of Retirement Option Form at Retirement allows a member who has applied for retirement
to select whether to receive their entire retirement allowance during their lifetime or to leave a lump
sum or allowance for their survivor(s). Descriptions and the amounts of a retirement allowance paid
pursuant to Options A, B and C are included on the form. Keep in mind:
l You may only select one Option.
l Please consult with your retirement board to be certain that you understand the effect of
selecting an Option. Your retirement board can provide you with a personalized estimate of
each benefit.
l If you are married, the Spousal Acknowledgement on this form must be signed by your spouse.
l A witness must sign page three of this form.
Introduction
Choice of Retirement Option Form at Retirement
Form Last Revised: March, 2002
COMMONWEALTH OF MASSACHUSETTS | PUBLIC EMPLOYEE RETIREMENT ADMINISTRATION COMMISSION
WEB | WWW.STATE.MA.US/PERAC
Choice of Retirement Option Form at Retirement
Form Last Revised: March, 2002
Member’s Information
Member’s Last Name (Print) First M.I. Date
Instructions
When you apply for retirement, you may select one of three retirement allowance payment Options
(A, B or C). For the Option selection to be valid, this completed form must be filed with your
retirement board:
l
on or before the date the board receives your written application for retirement, or
l
on or before the date your allowance becomes effective, or
l
not more than 15 days after the board receives a written application for your involuntary
retirement from your department head.
1.
You may change your Option selection before your retirement becomes effective by filing a new form.
2.
You may not change your Option selection once your retirement becomes effective.
3.
If no Option selection is made or none is in effect, your allowance will be paid under Option (B).
4. The spousal acknowledgement at the end of this form must be signed if you are married.
Selection of Retirement Option
After reviewing all retirement Options, please sign you name under only one of the Options.
Option (A) No Payment to Beneficiary
Your retirement allowance will be approximately $ annually for life and all payments will cease upon
your death. This Option provides for a full retirement allowance payable in monthly installments during your
lifetime. All allowance payments will cease upon your death and no benefits will be provided for any survivors.
To the Retirement Board
I choose to have my retirement allowance paid in accordance with the provisions of G.L. c. 32, § 12(2)(a) of
the General Laws which provides an allowance as explained above. I understand that this Option provides the
largest possible payment to me under the retirement law and that all payments thereunder cease at my death. I
also understand that by choosing this Option, I relinquish on the date that my retirement takes effect all claim
to my total accumulated deductions with interest and that upon my death my beneficiary (or estate) will have
no claim on these monies.
Member’s Signature ________________________________ Date________________
Member’s Social Security #
Retirement
Board: Please
place your address
and phone
number here.4
COMMONWEALTH OF MASSACHUSETTS | PUBLIC EMPLOYEE RETIREMENT ADMINISTRATION COMMISSION
WEB | WWW.STATE.MA.US/PERAC
Option (B) Lump Sum Payment to Beneficiary
Your retirement allowance will be approximately $ annually for life. The payments under this
Option are smaller than under Option (A). The annuity portion of your allowance is reduced to allow a lump
sum benefit for your named beneficiary(ies). Upon your death, your named beneficiary(ies), or if there is no
beneficiary living, the person or persons appearing in the judgment of the retirement board to be entitled
thereto will be paid the unexpended balance of your annuity account. Please note that the contributions com-
prising the annuity account will be depleted within approximately twelve to fifteen years depending upon your
age at retirement. The longer you live, the less will be paid to your beneficiary(ies) upon your death. If your
account has been fully depleted, nothing will be paid. You may designate and change at any time, one or more
beneficiaries to receive in designated proportions, or in the alternative, the lump sum Option (B) benefit. This
Option takes effect upon your retirement and supercedes any prior beneficiary selections.
BENEFICIARY’S NAME SSN OR TAX ID# PERCENTAGE
%
%
%
%
To the Retirement Board
I choose to have my retirement allowance paid in accordance with the provisions of G.L. c 32, § 12(2)(b)
which provides a cash refund annuity as explained above. I understand that this Option provides for a smaller
retirement allowance for life but that if I die before the amount which I have received in annuity payments
equals the sum of my total deductions with interest to the date of my retirement, the difference will be paid
to my designated beneficiary(ies).
Member’s Signature ________________________________ Date________________
Member’s Social Security #
Option (C) Payment of Allowance to Beneficiary
Your retirement allowance will be approximately $ annually for life. Election of Option (C) pro-
vides for a monthly retirement allowance during your lifetime that is less than you would receive under either
Option (A) or Option (B). Upon your death your designated beneficiary will be paid a monthly allowance for
the remainder of his or her lifetime. That allowance will be equal to two-thirds of the allowance that you
were receiving at the time of your death. The monthly allowance you receive under Option (C) is based upon
life expectancy factors for you and your designated beneficiary. Only your spouse, former spouse who has not
remarried, mother, father, sister, brother or child may be designated as your Option (C) beneficiary. The
younger your beneficiary, the lesser the amount of your retirement allowance. If, after you retire, your
Option (C) beneficiary predeceases you, you will thereafter be paid the full retirement allowance you would
have received had you elected Option (A) at the time your retirement allowance became effective. This con-
version is commonly referred to as the Option (C) “pop-up”. Please note that after the Option (C) “pop-up”
takes place you may not name another Option (C) beneficiary or choose another Option.
Choice of Retirement Option Form at Retirement 2
Member’s Last Name First M.I. Social Security #
Choice of Retirement Option Form at Retirement 3
To the Retirement Board:
I choose to have my retirement allowance paid in accordance with the provisions
of G.L. c. 32, § 12(2)(c) which provides an allowance as explained above. I understand that this retirement
allowance will be smaller than under Option (A) or Option (B) but that upon my death two-thirds of this
allowance will be paid to the named beneficiary for said beneficiary’s life.
Beneficiary’s Name Date of Birth
Relation to Member Social Security #
Member’s Signature ________________________________ Date________________
Member’s Social Security #
Witness
To the Retirement Board:
I have read this form with the member whose selection of an Option is made
on this document and at his or her request have witnessed his or her signature thereto.
Witness’ Signature ______________________________ Date ________________
Witness’ Name (Print)
Spousal Acknowledgment
For any member who is married, an election shall not be valid unless it is accompanied by the signature of the
member’s spouse indicating the member’s spouse’s knowledge and understanding of the retirement Option
selected. The retirement board shall provide the member and spouse with detailed information regarding the
benefit Option selected in order for the member and spouse to make an informed decision regarding said
Option. If any member who is married files an election which is not so accompanied, the board shall within
fifteen days notify the member’s spouse by registered mail of the Option election and of the spouse’s right to
sign and return an acknowledgment of receipt and understanding of such information within thirty days after
receipt of the acknowledgment. The election shall not take effect until it is accompanied by the signature of
the member’s spouse; provided, however, that no such signature shall be required if the spouse fails to sub-
mit such signed acknowledgment on or before the thirtieth day from receipt of the information from the
retirement board. Such election made prior to the spousal notification may be changed in accordance with
the spouse’s understanding of the retirement allowance selected, or at any later time otherwise permitted
under this chapter.
IMPORTANT: If you are the spouse of a member, please be certain you have read and understand the
foregoing provision relating to your spouse’s Option selection. If you do not understand any part of the
Option selected by your spouse, please ask for an explanation from your spouse’s retirement board. Your
signature is not consent or approval, only an acknowledgement of the Option chosen by your spouse.
l
Do not sign below unless you understand the Option selected by your spouse and the benefits to
which you may or may not be entitled to at his/her death.
Spouse’s Signature _________________________________ Date ________________
Spouse’s Name (Print)
Member’s Last Name First M.I. Social Security #
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