Public Employees’ Retirement System of Mississippi
429 Mississippi Street, Jackson, MS 39201-1005 800.444.7377 601.359.3589 601.359.6707, fax www.pers.ms.gov
Application for Recalculation of Benefits
Form R – Revised 06/01/2018
All six sections must be filled before submitting form to PERS. Only retiree named in Section 1 or an authorized representative may sign this
form. Please print or type in black ink. Completed form should be mailed or faxed to PERS. See bottom of form for contact information.
! Retiree Information – PERS will automatically update the mailing address on file with the mailing address listed below.
First Name:_______________________________________ MI: _________ Last Name: _______________________________________________________
Mailing Address: _________________________________________________ City: ____________________________ State: _______ Zip: _____________
Social Security No.: ________________________________ E-Mail: ________________________________________________________________________
Phone: _________________________________ ¨ Cellular ¨ Home ¨ Work Phone: ________________________________ ¨ Cellular ¨ Home ¨ Work
# Retirement Plan – Select applicable plan.
¨ Public Employees’ Retirement System of Mississippi (PERS) ¨ Mississippi Highway Safety Patrol Retirement System (MHSPRS)
¨ Supplemental Legislative Retirement Plan (SLRP)
$ Qualifying Event and Benefit Payment Option Selection – Select one.
¨ Death: My previously designated beneficiary under Base Option 2, 4, or 4A, as applicable, has died, and I request that my benefit be recalculated under
the Maximum Retirement Allowance or Base Option 9 for MHSPRS. Attach a copy of the death certificate. List at least one new beneficiary in
Section 4.
¨ Divorce: My previously designated beneficiary under Base Option 2, 4, or 4A, as applicable, and I have divorced, and I request that my benefit be
recalculated under the Maximum Retirement Allowance or Base Option 9 for MHSPRS. Attach a copy of the divorce decree. List at least one
new beneficiary in Section 4.
¨ Marriage: I am now married, and I request that my benefit be recalculated from the Maximum Retirement Allowance or Base Option 1 to the base
option selected below to provide beneficiary benefits to my spouse. Completed form must be received within one year of the date of the marriage.
Attach a copy of the marriage certificate and copies of your spouse’s birth certificate and Social Security card.
Before selecting a base option below, you must obtain an Estimate of Benefits from PERS.
¨ Option 2, 100 Percent Joint and Survivor Annuity for One Beneficiary ¨ Option 4, 75 Percent Joint and Survivor Annuity for One Beneficiary
¨ Option 4A, 50 Percent Joint and Survivor Annuity for One Beneficiary
% Beneficiary Designation – Select one.
¨ Beneficiary for Base Payment Options 2, 4, and 4A – Designate spouse as beneficiary under the applicable option if “Marriage” is your qualifying event.
Spouse’s Name Social Security No. Birth Date mm/dd/ccyy Marriage Date mm/dd/ccyy
_________________________________________
________________________________
__ _______________________ _____________________
¨ Beneficiary(ies) for unused contributions under the Maximum Retirement Allowance or Base Options 2, 4, 4A, or 9, as applicable – If more
than one primary beneficiary is listed, those primary beneficiaries will share equally unless otherwise noted. Secondary beneficiaries also will share
equally unless otherwise noted. Attach additional sheet if you wish to name more than two beneficiaries.
Beneficiary Name Social Security No. Birth Date Relationship Beneficiary Percentage
mm/dd/ccyy Use whole numbers
___________________________ ______________________ ________________ ______________________ ¨ Primary ¨ Secondary _____ %
___________________________ ______________________ ________________ ______________________ ¨ Primary ¨ Secondary _____ %
& Federal Tax Withholding Preference – Select one.
¨ I wish to have PERS determine the amount, if any, of federal tax to be withheld from my monthly benefit payment in accordance with the applicable tax
tables using the marital status and exemptions indicated below.
¨ Married ¨ Single Total No. of Exemptions Claimed: ______ Withhold an additional $_____________ from each monthly benefit payment.
¨ Rather than PERS determine the amount, I wish to have $______________ withheld from each monthly benefit payment.
¨ I do not wish to have federal withholding tax deducted from my monthly benefit payment. I understand that I am responsible for payment of
federal income tax on the taxable portion of my benefit.
' Applicant Authorization – Only retiree listed in Section 1 or an authorized representative may sign. If an authorized representative signs this form,
attach a copy of the durable power of attorney, conservatorship or guardianship papers, or other legal documents as proof of authority to sign this form.
I hereby revoke any previous base option selection and beneficiary designation on file in the physical office of PERS. I have reviewed and understand the
base options that are available to me. With that understanding, I agree that the base option which I have selected and the beneficiary(ies) that I have
designated above shall be effective upon filing of this application in the physical office of PERS in the event of my death after such filing.
Retiree/Authorized Representative Signature: _______________________________________________________ Date mm/dd/ccyy: ____________________
