%
IRA
%
Other Eligible Retirement Plan
IRA
_________________________________________________________ ______________________________
_________________________________________________________________________________________________
______________________________________________________________ _______________ __________________
Section 1
Provide your name as it
appears on your Social
Security card if you are a
U.S. citizen.
Refund Election Application
888 CalPERS (or 888-225-7377) • TTY: (877) 249-7442
Submit your refund application online through your myCalPERS account for a faster, more convenient
and secure refund.
Member Information
Name (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Address
City State Zip
______________________________________________________________ (_____)_________________________
____
Email Daytime Phone Number
Select this box if you are a nonmember refunding your community property account.
Section 2
Your direct rollover check
will be issued in the name
of your financial institution,
but we must mail it to your
home address. You are
required to deposit the
check with your financial
institution.
Distribution Option
Choose one of the following options for your CalPERS member/nonmember c ontributions and
interest refund:
Direct Payment to You: Attach a Refund Direct Deposit Authorization form, available on our website.
Federal withholding tax it is mandatory for us to withhold 20%.
California state withholding tax 2% will be automatically deducted from your refund amount, unless
you check the box below.
No Do not withhold state tax.
Rollover to another eligible retirement plan or Individual Retirement Account (IRA)
_________________________________________________________________ _______________
Name of Institution Other Eligible Retirement Plan Percent of Refund
_________________________________________________________________ _______________
Name of Institution IRA Percent of Refund
Combination of a Direct Payment to You and a Rollover to another eligible retirement plan or IRA.
Federal withholding tax it is mandatory for us to withhold 20%.
California state withholding tax 2% will be automatically deducted from your refund amount, unless
you check the box below.
No Do not withhold state tax.
_________________________________________________________________ %_______________
Name of Institution Other Eligible Retirement Plan Percent of Refund
_________________________________________________________________ %_______________
Name of Institution IRA Other Eligible Retirement Plan Percent of Refund
my|CalPERS-1202 Page 1 of 3
Your Name
________________________________________________________________________________________
________________________________________________________ _______________________________
______________________________________________________________ __________________________________
Put your name and Social
Security Number or CalPERS ID
at the top of every page
________________________________________________________________________________________
Social Security Number or CalPERS ID
Section 3
Sign this form in the
presence of a notary or
authorized representative
of CalPERS.
Spouse or Registered Domestic Partner Acknowledgment
Check the box if you are not married (i.e. divorced, widowed, or never married).
I am not legally married, nor do I have a registered domestic partner.
If you are married or have a Registered Domestic Partner, your spouse or registered domestic partner must
sign in the space provided below in the presence of a notary or authorized representative of CalPERS.
Spouse’s or Registered Domestic Partner’s Signature: You must sign this form in the presence of a notary
public or authorized representative of CalPERS.
By signing this form, I acknowledge my spouse’s or registered domestic partner’s request for a refund.
Print Name
Spouse’s or Registered Domestic Partner’s Signature
Date (mm/dd/yyyy)
If you are unable to locate your spouse or registered domestic partner, complete and include the
Justification for Absence of Spouse’s or Registered Domestic Partner’s Signature form, available on our
website at www.calpers.ca.gov.
Section 4
As the member requesting
a refund, you must sign this
form in the presence of a
notary or authorized
representative of CalPERS.
Refund Election Waiver of Rights
Please read, check the box provided below, and sign the following waiver of rights statement.
We cannot process a refund without your signature.
I hereby waive all potential future retirement, disability, and/or death benefits. I understand that by
refunding my contributions, I am forfeiting all future benefits, including any appeal cases pending with
CalPERS, and am terminating my CalPERS membership, unless I am a vested member under the State
Second Tier.
By signing this form, I understand this decision is irrevocable. Once this application is processed, it
cannot be cancelled.
I certify under penalty of perjury under the laws of the State of California, that the foregoing information
is true and correct.
Signature Date (mm/dd/yyyy)
my|CalPERS-1202 Page 2 of 3
Social Security Number or CalPERS ID
personally appeared
___________________________________________ ___________________________________________
___________________________________________ _____________________ ____________________
___________________________________________ _________________________________________
Put your name and Social
Security number or CalPERS ID
at the top of every page
_________________________________________________________________________________________
Your Name
Section 5
This section is to be
completed at the same
time as Sections 3 and 4.
Notary Public Acknowledgment
State of California, County of ________________________________________________________________
On _________________________ before _____________________________________
Date (mm/dd/yyyy) Printed Name of Notary Public or Witness
Name(s) of Principal(s)
Who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to
the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized
capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of
which the person(s) acted, executed the instrument. I certify under Penalty of Perjury under the laws of the
State of California that the foregoing paragraph is true and correct.
A notary public or other officer completing this certificate verifies only the identity of the individual who
signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity
of that document.
Notary Seal
Witness my hand and official seal or authorized CalPERS representative’s signature.
Signature of Notary or CalPERS Representative Position Title Date (mm/dd/yyyy)
Printed Name CalPERS Office (if applicable)
Mail to: CalPERS Member Account Management Division P.O. Box 942704, Sacramento, California 94229-2704
my|CalPERS-1202 Page 3 of 3
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
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