Section 1
Member Information
Name of Member (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Pursuant to Government Code section 21261, an election of optional settlement, designation of beneficiary, or
change in beneficiary shall contain the signature of the current spouse or registered domestic partner unless the
retirement payment option provides him or her 100 percent of the member’s monthly allowance and he or she was
also named as the sole beneficiary for any lump-sum benefits.
If a spouse’s or registered domestic partner’s signature is required and he or she is unable to sign
the retirement application or beneficiary designation form, the following information must be completed
by the member.
By checking this box, I indicate that I am married or have a registered domestic partner, but my spouse
or registered domestic partner did not sign this form because:
I do not know and have taken all reasonable steps to determine the whereabouts of my spouse
or registered domestic partner; or
My spouse or registered domestic partner has been advised of the application and has refused
to sign the written acknowledgment; or
My spouse or registered domestic partner is incapable of executing the acknowledgment because
of an incapacitating mental or physical condition; or
My spouse or registered domestic partner has no identifiable community property interest
in the benefit; or
My spouse or registered domestic partner and I have executed a marriage settlement or partnership
agreement that makes the community property law inapplicable to the marriage or partnership.
Mail to:
CalPERS Retirement Benefit Services Division P.O. Box 942711, Sacramento, California 94229-2711
Section 2
Information Certification
I certify under penalty of perjury that the foregoing information is true and correct.
Signature of Member Date (mm/dd/yyyy)
888 CalPERS (or 888-225-7377)
TTY: (877) 249-7442
Justification for Absence of Spouse’s
or Registered Domestic Partner’s Signature
PERS-BSD-800A (12/19) Page 1 of 1
Privacy Notice
The privacy of personal information is of the utmost importance to CalPERS.
The following information is provided to you in compliance with the Information
Practices Act of 1977 and the Federal Privacy Act of 1974.
Information Purpose
The information requested is collected pursuant
to the Government Code (sections 20000 et seq.)
and will be used for administration of Board
duties under the Retirement Law, the Social
Security Act, and the Public Employees’ Medical
and Hospital Care Act, as the case may be.
Submission of the requested information is
mandatory. Failure to comply may result in
CalPERS being unable to perform its functions
regarding your status.
Please do not include information that is
not requested.
Social Security Numbers
Social Security numbers are collected on a
mandatory and voluntary basis. If this is CalPERS’
first request for disclosure of your Social Security
number, then disclosure is mandatory. If your
Social Security number has already been provided,
disclosure is voluntary. Due to the use of Social
Security numbers by other agencies for
identification purposes, we may be unable to
verify eligibility for benefits without the number.
Social Security numbers are used for the
following purposes:
1. Enrollee identification
2. Payroll deduction/state contributions
3. Billing of contracting agencies for employee/
employer contributions
4. Reports to CalPERS and other state agencies
5. Coordination of benefits among carriers
6. Resolving member appeals, complaints,
or grievances with health plan carriers
Information Disclosure
Portions of this information may be transferred
to other state agencies (such as your employer),
physicians, and insurance carriers, but only
in strict accordance with current statutes
regarding confidentiality.
Your Rights
You have the right to review your membership
files maintained by the System. For questions
about this notice, our Privacy Policy, or your rights,
please write to the CalPERS Privacy Ocer at
400 Q Street, Sacramento, CA 95811 or call us
at 888 CalPERS (or 888-225-7377).
May 2016