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
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
Member’s Last Name First M.I. Social Security #