Fillable NEW MEMBER ENROLLMENT FORM (Town of East Longmeadow)

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NEW MEMBER ENROLLMENT FORM (Town of East Longmeadow)

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NEW MEMBER ENROLLMENT FORM
Hampden County Regional Retirement Board
67 Hunt Street – Suite 116
Agawam, Massachusetts 01001
Telephone Number: (413) 737-1344 Fax Number: (413) 732-7999
EMPLOYEE NAME SS# SEX
(Last) (First) (Middle)
BIRTH NAME (If Different) DATE OF BIRTH:
AGE: # of Children SPOUSE DATE OF BIRTH:
MARITAL STATUS M S W D
MEMBER UNIT/DEPARTMENT TITLE/POSITION
STARTING DATE OF PRESENT SERVICE HOURS PER WORK
REGULAR COMPENSATION PER WEEK BI/WEEKLY MONTHLY
Please list any previous or concurrent employment with the Commonwealth of Massachusetts or with any other
City/Town or County, (State place of employment, dates and name if different from above.)
Were you ever a member of any other Public Retirement System? Is “YES”, did you withdraw your funds?
Name of Retirement System (If your funds were withdrawn and you wish to redeposit,
you must submit a written request to the Hampden County Regional Retirement Board.)
Are you currently or have you ever received a retirement allowance from another public retirement system?
Are you a Veteran? Date of Active Service:
*A COPY OF BIRTH CERTIFICATE & MILITARY DISCHARGE PAPERS
MUST BE FILED WITH THE RETIRMENT BOARD
I have carefully and truthfully filled out this form. I hereby authorize the Treasurer to withhold the proper percent of my regular
compensation due on each pay day and to deposit such deductions to my credit in the annuity savings funds. I understand the
full amount of such deduction, with compound interest if provided by the retirement act will be returned to me upon request if I
terminate my service before becoming eligible for retirement unless to accept a position which would entitle me to become a
member of any other similar contributory retirement system in the Commonwealth, or will be paid to my beneficiary or
beneficiaries if provided by the retirement act in case of death.
The above statements are true and correctly recorded to the best of my knowledge and belief and are made under the penalties
of perjury.
DATE: EMPLOYEE’S SIGNATURE:
TO BE COMPLETED BY PAYROLL DEPARTMENT:
Please check all appropriate boxes: 5% 7% 7%+2% 8% 8%+2% 9% 9%+2%
Permanent Temporary Full Time Part-time
DATE: AUTHORIZED SIGNATURE:
TO BE COMPLETED BY THE RETIREMENT BOARD:
Membership Date: Annual Compensation: $ % Group:
FORM MUST BE COMPLETED IN ITS ENTIRETY AND BENEFICIARY DESIGNATED ON THE REVERSE SIDE
PERA 9-1-76
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NOMINATION OF BENEFICIARY
G.L. chapter 32, Section 11(2)(c). Any member, upon his written notice on a prescribed form filed with the
board prior to his death, may nominate, and from time to time change, one or more beneficiaries to receive in
designated proportions any sum becoming payable under the provisions of this subdivision on his/her death;
provided, that any such beneficiary nominated by a minor shall be of his kindred. The payment of any such
sum or portion thereof to his beneficiary or beneficiaries of record surviving at his death shall bar the recovery
of such payment by any other person. If there is no beneficiary of record or if any beneficiary of record is not
living at the death of such member, such sum or the amount which would have been paid to such beneficiary if
he had survived such member, as the case may be, shall be paid to the legal representatives of such member;
provided, that if any such sum or amount does not exceed three hundred dollars, and if there has been no written
demand upon the Board for payment thereof by a duly appointed executor or administrator of the estate of such
member and the Board has not otherwise been informed that probate proceedings relative to such estate have
been commenced, such sum or amount may be paid after the expiration of ninety days from the date of death of
such member, to the person or persons appearing in the judgment of the Board to be entitled thereto. The pay-
ment of any such sum or amount in such a manner, or to the natural or legal guardian or conservator of a minor
or incompetent beneficiary, shall constitute a legal settlement of all claims on account thereof to the extent of
such payment and shall bar recovery of such payment by any other person.
Payment shall not be made under this subdivision if the deceased member is survived by a beneficiary
appointed under Option (d) of subdivision (2) of Section 12 who is eligible to receive the allowance provided by
said option, nor if the deceased member is survived by a person eligible to receive the allowance provided for in
Section 12B, or is survived by a child eligible to receive the allowance provided for in Section 12B, unless the
widow or person acting for such child elects, in lieu of receiving allowances provided for in said Section 12B,
to have payment of any monies due made in accordance with the provision of this paragraph.
Beneficiary or beneficiaries nominated will receive in the proportion designated any sum due at your death.
The right to change any nominated beneficiary is reserved by the member.
A BENEFICIARY BLANK WITH CORRECTIONS OR ERASURES IS NOT ACCEPTABLE
NAME AND ADDRESS OF BENEFICIARY
SOC SECURITY#
BENEFICIARY
DATE OF BIRTH
RELATIONSHIP
TO MEMBER
PERCENTAGE
OF BENEFIT
DATE: SIGNATURE OF EMPLOYEE:
SIGNATURE OF WITNESS:
(A CHANGE OF BENEFICIARY FORM must be used if you wish to change your designated beneficiary or
beneficiaries. You may obtain said form from this Retirement Board.)
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Statement Concerning Your Employment in a Job
Not Covered by Social Security
Employee Name Employee ID#
Employer Name Employer ID#
Your earnings from this job are not covered under Social Security. When you retire, or if you become disabled, you
may receive a pension based on earnings from this job. If you do, and you are also entitled to a benefit from Social
Security based on either your own work or the work of your husband or wife, or former husband or wife, your
pension may affect the amount of the Social Security benefit you receive. Your Medicare benefits, however, will not
be affected. Under the Social Security law, there are two ways your Social Security benefit amount may be affected.
Windfall Elimination Provision
Under the Windfall Elimination Provision, your Social Security retirement or disability benefit is figured using a
modified formula when you are also entitled to a pension from a job where you did not pay Social Security tax. As a
result, you will receive a lower Social Security benefit than if you were not entitled to a pension from this job. For
example, if you are age 62 in 2005, the maximum monthly reduction in your Social Security benefit as a result of
this provision is $313.50. This amount is updated annually. This provision reduces, but does not totally eliminate,
your Social Security benefit. For additional information, please refer to Social Security Publication, “Windfall
Elimination Provision.”
Government Pension Offset Provision
Under the Government Pension Provision, any Social Security spouse or widow(er) benefit to which you become
entitled will be offset if you also receive a Federal, State or local government pension based on work where you did
not pay Social Security tax. The offset reduces the amount of your Social Security spouse or widow(er) benefit by
two-thirds of the amount of your pension.
For example, if you get a monthly pension of $600 based on earnings that are not covered under Social Security,
two-thirds of that amount, $400, is used to offset your Social Security spouse or widow(er) benefit. If you are
eligible for a $500 widow(er) benefit, you will receive $100 per month from Social Security ($500 - $400=$100).
Even if your pension is high enough to totally offset your spouse or widow(er) Social Security benefit, you are still
eligible for Medicare at age 65. For additional information, please refer to Social Security Publication, “Government
Pension Offset.”
For More Information
Social Security publications and additional information, including information about exceptions to each provision,
are available at www.socialsecurity.gov
. You may also call toll free 1-800-772-1213, or for the deaf or hard of
hearing call the TTY number 1-800-325-0778, or contact your local Social Security office.
I certify that I have received Form SSA-1945 that contains information about the possible effects of the
Windfall Elimination Provision and the Government Pension Offset Provision on my potential future Social
Security benefits.
Signature of Employee Date
Form SSA-1945 (12-2004)
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Information about Social Security Form SSA-1945
Statement Concerning Your Employment in a Job Not Covered by Social Security
New legislation [Section 413(c) of Public Law 108-203, the Social Security Protection Act of 2004] requires
State and local government employers to provide a statement to employees hired January 1, 2005 or later in a
job not covered under Social Security. The statement explains how a pension from that job could affect future
Social Security benefits to which they may become entitled.
Form SSA-1945, Statement Concerning Your Employment in a Job Not Covered by Social Security, is the
document that employers should use to meet the requirements of the law. The SSA-1945 explains the potential
effects of two provisions in the Social Security law for workers who also receive a pension based on their work
in a job not covered by Social Security. The Windfall Elimination Provision can affect the amount of a
worker’s Social Security retirement or disability benefit. The Government Pension Offset Provision can affect a
Social Security benefit received as a spouse or an ex-spouse.
Employers must:
Give the statement to the employee prior to the start of employment;
Get the employee’s signature on the form; and
Submit a copy of the signed form to the pension paying agency.
Social Security will not be setting any additional guidelines for the use of this form.
Copies of the SSA-1945 are available online at the Social Security website, www.socialsecurity.gov/form1945.
Paper copies can be requested by email at oplm.oswm.rqct.orders@ssa.gov or by fax at 410-965-2037. The
request must include the name, complete address and telephone number of the employer. Forms will not be sent
to a post office box. Also, if appropriate, include the name of the person to whom the forms are to be delivered.
The forms are available in package of 25. Please refer to Inventory Control Number (ICN) 276950 when
ordering.
Form SSA-1945 (12-2004)
HAMPDEN COUNTY REGIONAL RETIREMENT SYSTEM
67 HUNT STREET, SUITE 116 AGAWAM, MA 01001
TELEPHONE: (413) 737-1344; FAX NUMBER: (413) 732-7999
PRIOR MASSACHUSETTS PUBLIC EMPLOYMENT INFORMATION
NEW MEMBERS IN THE SYSTEM EFFECTIVE APRIL 2, 2012
Please be advised, that with the passage of Chapter 176 of the Acts of 2011 there is now a one year time
limit from the date of membership in the retirement system to purchase prior retirement service with a
public employer in the Commonwealth of Massachusetts at a reduced interest rate of one-half (1/2) of the
Hampden County Regional Retirement System’s assumed actuarial rate of return. If the service is not
purchased within this one year period, the member will be charged interest at a rate equal to the full actuarial
assumed rate of return.
If you do not have any prior service with another public employer in the Commonwealth of
Massachusetts, please indicate such, sign and date this form where indicated below and return this form along
with the New Member Enrollment Form to the Hampden County Regional Retirement Board at the address
listed above.
If you do have prior service with a public employer in the Commonwealth of Massachusetts and either
took a refund of your annuity savings fund from the retirement system or were never contributing to the
retirement system for the time period please provide the Hampden County Regional Retirement Board with the
details of the service below so we may contact the other retirement system or Massachusetts public employer.
Upon receipt of the information requested, the Hampden County Regional Retirement System will provide you
with information regarding the cost in purchasing the time. Return this form along with your New Membership
Enrollment Form to the Hampden County Regional Retirement System at the address listed above. If you have
any questions, please do not hesitate to contact the Retirement Board. (Please attach a list of additional
municipal employment if more space is required.)
Check Box:
I DO NOT HAVE ANY PRIOR MASSACHUSETTS PUBLIC EMPLOYMENT
I DO HAVE PRIOR MASSACHUSETTS PUBLIC EMPLOYMENT AS LISTED BELOW:
Municipal Employer Dates Refund Y/N
Municipal Employer Dates Refund Y/N
Municipal Employer Dates Refund Y/N
Municipal Employer Dates Refund Y/N
Member’s Name Please Print
Member’s Signature Social Security Number Date
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NEW MEMBER ENROLLMENT FORM (Town of East Longmeadow)

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Completed 3 August 2020

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