I do not know, and have taken all reasonable steps, to determine the
whereabouts of my spouse/domestic partner.
My spouse/domestic partner has been advised of this election and has refused
to sign the document(s).
My spouse/domestic partner is incapable of signing the document(s) because of an
incapacitating mental or physical condition.
My spouse/domestic partner has no identifiable community property interest in the
benefit.
My spouse/domestic partner and I have executed a marriage settlement
agreement which makes the community property law inapplicable to the marriage
_______________
California Public Employees’ Retirement System
Member Account Management Division
P.O Box 942715, Sacramento, CA 94229-2715 | Fax: (800) 959-6545
888 CalPERS (or 888-225-7377) | TTY: (877) 249-7442 | www.calpers.ca.gov
Justification for Absence of Spouse or Registered Domestic Partner’s Signature
Election to the First Tier
StateMiscellaneous or IndustrialRetirement Formula
Pursuant to Government Code Section 21073.7, the participant's current spouse or registered domestic
partner must be made aware of the selection of benefits by the participant. The spouse or registered
domesticpartner of a CalPERSParticipant must acknowledge the submission of the Election Document
for the First Tier retirement formula.
If the spouse’s or registered domestic partner's is not able to sign the document, this form MUST be
completed by the participant and submitted with the document.
Participant Name: CalPERS ID or SSN:
I am married/registered, but my spouse/domestic partner did not sign the form
because:
I CERTIFY UNDER PENALTY OF PERJURY THAT THIS INFORMATION IS TRUE AND CORRECT.
Participant Signature: ____________________________________Date:
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