The Application for Voluntary Superannuation Retirement allows a member to apply to receive a
superannuation (regular) retirement allowance. You may also apply for a Termination
Retirement Allowance on this form. The eligibility requirements for superannuation retirement
are listed on the form. Keep in mind:
A properly completed Choice of Retirement Option Form at Retirement must accompany this
application.
A copy of your birth certificate, military discharge papers, marriage certificate and any
other relevant documents must be filed with this application.
Introduction
Application for Voluntary Superannuation Retirement
Form Last Revised: November, 2011
COMMONWEALTH OF MASSACHUSETTS | PUBLIC EMPLOYEE RETIREMENT ADMINISTRATION COMMISSION
WEB | WWW.MASS.GOV/PERAC
Eligibility Requirements for Superannuation Retirement
If you are a member of Group 1 or 2, you are eligible to retire at any age with at least twenty years of
creditable service. If you last became a member of a retirement system prior to January 1, 1978 you may,
as a member in service, retire at 55 with any number of years of service. If you last became a member of a
retirement system on or after January 1, 1978 and you have less than 20 years of creditable service, you must
have at least ten years of creditable service and be at least age 55 to retire. If you are a member of Group 4,
you are eligible to retire at any age with 20 years of creditable service or at age 55. The amount of your allow-
ance depends on your age, creditable service, group classification and salary.
If you are an active employee or on leave of absence, you can apply for retirement with the board
no earlier than four months before your intended date of retirement.
Applicant Information
To the Retirement Board:
I respectfully request retirement for superannuation in retirement Group as of with
years and months of creditable service under the provisions of G.L. c. 32, §§ 1-28.
In connection with my application, I certify the following:
I AM RETIRING FROM
Agency or Department* Title/Position
MY PRESENT ADDRESS
Street and Number
City/Town State Zip Phone #
Date of Birth Social Security #
MY ADDRESS AFTER RETIREMENT (Enter only if different from present address)
Street and Number
City/Town State Zip Phone #
Application for Voluntary Superannuation Retirement
Form Last Revised: November, 2011
Retirement
Board: Please
place your address
and phone
number here.
COMMONWEALTH OF MASSACHUSETTS | PUBLIC EMPLOYEE RETIREMENT ADMINISTRATION COMMISSION
WEB | WWW.MASS.GOV/PERAC
Member’s Last Name First M.I. Social Security #
RETIREMENT BOARD ADDRESS
Street and Number
City/Town State Zip Phone #
1
Employment History
Please supply all periods of service and specify any temporary or irregular service.
I was also employed by other governmental units/political subdivisions in the Commonwealth of Massachusetts
as follows:
UNIT DEPARTMENT POSITION DATES EMPLOYED
Are you presently receiving a retirement allowance from any retirement system of
any governmental units/political subdivisions within the Commonwealth of Massachusetts? Yes No
If yes, please specify systems, date of retirement and retirement type.
Are you a veteran? Yes No
If yes, please specify military branch and dates of active service.
Have you been officially investigated for or charged with misappropriation of funds from your employer or
convicted of any crime related to your office or position? Yes No
If yes, please provide documentation.
If you are applying for retirement by reason of resignation, failure of re-election or reappointment, removal or
discharge under the provisions of G.L. c. 32, § 10; please briefly summarize the facts:
Have you engaged in the practice of shift substitution on or after October 26, 2011? Yes No
I sign this application under the pains and penalties of perjury. I affirm that the information presented
in this application is correct, complete and accurately presented. I understand that giving false or incomplete
information may subject me to the loss of my benefits as well as civil and criminal penalties.
Applicant’s Signature __________________________________ Date __________
Applicant’s Name (Print)
The following must be filed by you or your beneficiary with your retirement board:
A properly completed Application for Voluntary Superannuation Retirement (this form).
A properly completed Choice of Retirement Option Form at Retirement.
A copy of your birth certificate, military discharge papers, marriage certificate, and/or other records appli-
cable to your retirement.
* For those retiring from regional or county retirement systems, please identify the community.
Application for Voluntary Superannuation Retirement 2
From To
From To
From To
Member’s Last Name First M.I. Social Security #
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