This is a request for an estimate of your potential CalPERS retirement benefit amounts. You must be within one year
of your anticipated retirement date to use this form. You are limited to two estimate requests within a 12-month period.
Retirement Allowance Estimate Request
Your Name (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Birth Date (mm/dd/yyyy) Daytime Phone Alternate Phone
Address
City State ZIP
( ) ( )
Enter the address we
have on file for you.
If you need to update
your address, see the
back of this form
for instructions.
Section 1
Information About You
Section 2
Your Retirement Information
You can only select
one type of retirement
estimate per form.
What is a survivor vs. a
beneficiary? See the back
of this form for details and
a complete description of
the available retirement
payment options.
Choose one type:
c
Service Retirement
c
Disability Retirement
c
Industrial Disability Retirement
My projected retirement date is:
Employer Position Title
To include your unused sick leave and/or educational leave in your estimate, enter the number of hours you’ll
have as of your projected retirement date. See the back of this form for eligibility requirements.
Sick Leave Hours Educational Leave Hours
Will you have an eligible survivor on your projected retirement date?
c
Yes
c
No
How many beneficiaries do you want to include in your estimate?
c
None
c
One (Complete the information in the space provided below.)
Name of Beneficiary Relationship to You Birth Date (mm/dd/yyyy)
c
One or more and with a specific dollar or specific percentage amount to each beneficiary.
(Complete the information in the spaces provided below.)
If you are a member of a defined benefit plan with another California public retirement system and want
us to use your final compensation with the other system in your estimate, complete the information below.
Name of Reciprocal System Estimated Final Compensation Amount
If you want to include temporary annuity in your retirement estimate, select one of the choices below.
c
I became a member prior to January 1, 2002, and elect to receive temporary annuity until
age in the amount of $ per month.
c
I became a member on January 1, 2002, or later and have CalPERS service coordinated with Social
Security. I elect to receive temporary annuity until age in the amount of $
per month.
(62 to 70)
Dollars
(59
1
/
2
or whole age 60 to 68)
Dollars
Date Required (mm/dd/yyyy)
Section 3
Advanced Estimate Scenarios
See the back of this
form for information
regarding the Advanced
Estimate Scenarios.
Birth Date (mm/dd/yyyy) Dollar or Percent of Benefit
Birth Date (mm/dd/yyyy) Dollar or Percent of Benefit
Birth Date (mm/dd/yyyy) Dollar or Percent of Benefit
Birth Date (mm/dd/yyyy) Dollar or Percent of Benefit
Mail to:
CalPERS Retirement Benefit Services Division P.O. Box 942711, Sacramento, California 94229-2711
888 CalPERS (or 888-225-7377)
TTY: (877) 249-7442
PERS-BSD-470 (11/19) Page 1 of 1
Section 1
Information About You
If you are an active CalPERS member, contact your personnel office and ask them to update your mailing address with us.
If you are an inactive CalPERS member, update your address at my.calpers.ca.gov or call us toll free at 888 CalPERS
(or 888-225-7377).
Section 2
Your Retirement Information
Retirement Date - Your retirement date can be no earlier than your last day on payroll. If it has been more than nine months
since you left employment, the date you enter cannot be earlier than the first day of the month you submit this form.
Unused Sick Leave/Educational Leave - Your last employer must contract to provide this benefit, and you must retire within
120 days of leaving employment for any unused sick and/or educational leave to be included in your actual retirement benefit.
What is a survivor? - A survivor receives a monthly benefit regardless of the retirement payment you choose. We only
include this in your retirement estimate if your employer contracts to provide this benefit. A survivor is defined by law as:
a spouse or registered domestic partner who was married or registered to you for at least one year before your service
retirement date and continuously until your death. (For disability or industrial disability retirement, these conditions
must be met on or before the effective date of your disability or industrial disability retirement.)
natural or adopted unmarried children under age 18.
an unmarried child who was disabled prior to age 18 and whose disability continues without interruption until
the disability ends or until marriage.
qualifying financially dependent parents, if none of the above.
What is a beneficiary? - A beneficiary is any person you choose to receive either a one-time lump-sum payment
or ongoing monthly benefit upon your death.
Retirement Options - When you retire, you will choose one of the following retirement options and name a beneficiary.
Unmodified Allowance - Provides the highest monthly allowance paid for life. There is no continuing monthly benefit
to a beneficiary and no return of unused member contributions upon your death.
Return of Remaining Contributions Option 1 - Provides a lump-sum payout of any remaining member contributions
in your account to one or more beneficiaries upon your death.
100 Percent Beneficiary Option 2 - Provides 100 percent of the option portion of your ongoing monthly benefit to your
named beneficiary upon your death. Upon both your deaths a lump-sum payout of any remaining member contributions
in your account will be paid to one or more named secondary beneficiaries.
100 Percent Beneficiary Option 2 with Benefit Allowance Increase - Provides 100 percent of the option portion of
your monthly benefit to your named beneficiary upon your death. If your beneficiary dies before you, or if you have another
qualifying event, your benefit will increase to the Unmodified Allowance.
50 Percent Beneficiary Option 3 - Provides 50 percent of the option portion of your ongoing monthly benefit to your
named beneficiary upon your death. Upon both your deaths, a lump-sum payout of any remaining member contributions
in your account will be paid to one or more named secondary beneficiaries.
50 Percent Beneficiary Option 3 with Benefit Allowance Increase - Provides 50 percent of the option portion of your
ongoing monthly benefit to your named beneficiary upon your death. If your beneficiary dies before you, or you have
another qualifying event, your benefit will increase to the Unmodified Allowance.
Flexible Beneficiary Option 4 - Provides an ongoing monthly benefit of a specific dollar amount or percentage of your
Unmodified Allowance to one or more named beneficiaries upon your death.
Section 3
Advanced Estimate Scenarios
Reciprocity
Enter the name of the other California public retirement system you are a member of.
Enter your highest average annual compensation for any consecutive 12- or 36-month period of employment
with the other retirement system.
To be eligible for full reciprocal benefits, such as final compensation exchange, you must retire concurrently.
Refer to the publication When You Change Retirement Systems (PUB 16) for detailed information.
Temporary Annuity
This benefit is only available for a service retirement.
Enter the amount you want to receive and to what age depending on your CalPERS membership date.
If your membership is on or after January 1, 2002, your temporary annuity amount cannot exceed your estimated Social
Security benefit. This benefit is not free. Refer to the publication Temporary Annuity (PUB 13) for detailed information.
PERS-BSD-470 (11/19)
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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