The New Member Enrollment Form allows a newly hired employee to apply for membership in a
public retirement system. The form must be completed by any eligible new employee regardless
of his or her past employment with any governmental entity. Certain information on this form
must be provided by the Payroll/Personnel Department and verified by the Retirement Board. A
member's beneficiary to receive a refund of the member's total accumulated deductions is now
selected on the Beneficiary Selection Form.
Introduction
New Member Enrollment Form
Form Last Revised: October, 2001
COMMONWEALTH OF MASSACHUSETTS | PUBLIC EMPLOYEE RETIREMENT ADMINISTRATION COMMISSION
WEB | WWW.STATE.MA.US/PERAC
Last First M.I. Social Security # Sex
Address
Street and Number City/Town State Zip Phone #
Birth Name or Former Name
(if different)
Date of Birth
*
Marital Status
Spouse’s Name Spouse’s Date of Birth # of Children
Agency or Department
**
Title/Position Starting Date of Present Service
* The retirement board may request a copy of birth records, miltary discharge papers and other
pertinent data.
** For those retiring from regional or county retirement system, please indentify the community.
Are you retired from any other Massachusetts public retirement system? Yes No
Were you ever a member of any other Massachusetts public retirement system? Yes No
List prior or current public retirement system membership:
SYSTEM DATES OF MEMBERSHIP
If you wish to purchase past creditable service, you must make that request in writing of the relevant retirement system and
produce acceptable proof of such service.
Did you ever work for or do you currently work for the Commonwealth or Yes No
one of its political subdivisions for which you were not/are not a contributing
member of a retirement system?
New Member Enrollment Form
Form Last Revised: October, 2001
COMMONWEALTH OF MASSACHUSETTS | PUBLIC EMPLOYEE RETIREMENT ADMINISTRATION COMMISSION
WEB | WWW.MASS.GOV/PERAC
Retirement
Board: Please
place your address
and phone
number here.4
M S W
D
Yes No
Yes No
Yes No
Employee Name
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ARE YOUR FUNDS
STILL ON DEPOSIT?
List prior or current employment with the Commonwealth or one of its political subdivisions
(Non-membership) :
EMPLOYER DATES OF EMPLOYMENT
Are you a Veteran?
*
Yes No Dates of Active Duty Service
* The retirement board may request a copy of birth records, miltary discharge papers and other
pertinent data.
I hereby authorize the Treasurer to withhold the proper percent of my regular compensation due on each pay
period and to deposit such deductions to my credit in the annuity savings fund. I understand the full amount of
such deductions, with regular interest as provided by law, will be returned to me upon my written request if
I terminate my service, unless I plan to accept a position which would entitle me to become a member of any
other contributory retirement system in the Commonwealth. In the event that I die before retiring, my beneficiary
or beneficiaries may receive survivor benefits or a refund of my accumulated total deductions as allowed by law.
I sign this form under the pains and penalties of perjury. I affirm that the information presented in this form is cor-
rect, 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.
Employee’s Signature ________________________________________ Date: ___________
To Be Completed by Payroll/Personnel Department and Verified by Retirement Board:
Check base rate to be deducted for retirement:
5% 7% 8% 9% Additional 2%
If 5% or 7% or 8%, state reason:
Current Rate of Regular Compensation per Pay Period:
Employment Status (Check all that apply):
Permanent Temporary Full-time Part-time: 50% 75% Other _____
Authorized Signature: ________________________________________ Date: ___________
Print Name
To Be Completed by the Retirement Board:
Membership Date $ Annual Regular Compensation % to be deducted
Group Classification
The member must also complete the
Beneficiary Selection Form.
New Member Enrollment Form 2
Member’s Last Name First M.I. Social Security #
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