Fillable Retirement Application Form

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Retirement Application Form

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  • 16 check-boxes
  • 15 other fields

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Box 7:
Check Service (Normal Retirement) if you are a general employee age 65 or older with five years of creditable service (age
60 for sworn public safety officers).
Box 12:
Boxes 13 - 17:
Box 18:
Please read the certification statement before signing and dating the application. Your signature must be notarized. Your
application is not valid until properly signed, dated and notarized.
Check the benefit payment option of your choice. Refer to the So You've Made the Decision to Retire... Now What?
handbook to determine which payment option will meet your retirement goal. If you elect one of the survivorship options,
you must indicate the percentage (25, 50, 75 or 100) of your retirement benefit that you wish to leave to your designated
survivor.
Complete these boxes only if you elected one of the survivorship options in Box 10. If you choose a survivorship option,
you must submit proof of your designated survivor's age (preferably a copy of the designated survivor's birth certificate.)
Boxes 1 - 6:
Enter your personal data.
Check Early Service (Age & Service) if you are a general employee at least age 55, and have completed at least five years
of creditable service, or are a sworn public safety officer at least age 50, with at least five years of creditable service.
Check Early Service (Service) if you are a general employee younger than age 55 or a sworn public safety officer younger
than age 50, and are eligible for an unreduced benefit based strictly on your years of service. To satisfy this requirement,
general employees must have 30 years of service and sworn public safety officers must have 25 years of service if
participating in the DB Plan, or 20 years of service if participating in the EDB Plan.
Box 8:
Box 9:
Enter your official job title.
Enter the date you plan to retire (which must be the first day of the month).
Box 10:
Box 11:
Check Deferred Service if you are a former vested general employee age 65 or older or a former vested sworn public safety
officer age 60 or older.
Check Deferred Early Service if you are a former vested general employee at least age 55 but less than age 65 or a sworn
public safety officers at least age 50 but less than age 60.
Check Deferred Early Service (DC Plan) if you are a vested member of the Defined Contribution Plan who with a frozen
retirement benefit as a former member of the Defined Benefit (DB) Plan, and have met the eligibility requirements for
retirement.
Check one of the membership plans listed. Your membership plan can be found on your Estimate of Benefits Statement or
the most recent Annual Estimated Pension Statement (active employees only).
INSTRUCTIONS FOR COMPLETING THE RETIREMENT
APPLICATION
You must include a certified copy of your birth certificate with your application. If you do not have a copy of your birth certificate, please submit one of
the documents from the list of Acceptable Documents for Proof of Age located on the System's web site.
Enter the name of your department.
Complete this application if you are a member of the Defined Benefit Plan and are applying for a Service/Early Service retirement (retiring from active
employment) or a Deferred Service/Early Service retirement (former employee with vested rights). Your application must be received in the Richmond
Retirement System's office at least sixty (60) days, but no more than ninety (90) days before your effective retirement date.
Please read the So You've Made the Decision to Retire… Now What? handbook before completing your application. You may access this handbook at
the Richmond Retirement System's website (www.richmondgov.com/retirement).
MEMBER RESPONSIBILITIES: COMPLETE PARTS A THROUGH F
730 East Broad Street
Suite 900
Richmond, VA 23219
RICHMOND RETIREMENT SYSTEM
www.richmondgov.com/retirement
Phone 804.646.5958
Fax 804.646.5299
10. Membership Plan (Choose One) o Defined Benefit o Defined Benefit With Enhanced Option o Defined Contribution
11. Type of Retirement
o Early Service (Age & Service) o Early Service (Service)
12. Benefit Payment Option (Choose One) o Basic Benefit o Level Payment o Smooth-Out
o______ % Pop-Up Joint and Last Survivorship o______ %Joint and Last Survivorship
(25%, 50%, 75%, 100%)
(25%, 50%, 75% or 100%)
15. Birth Date:
17. Relationship: o Spouse o Other
PART D. SURVIVOR INFORMATION (Only complete Part D if you chose a survivor option in Part C)
2. Social Security Number:
3. Birth Date:
4. Address:
6. Email Address:
14. SSN:
PART B. TYPE OF RETIREMENT
My Commission Expires:
Members Creditable Service:
2nd Reviewer:
1st Reviewer:
Date:
Date:
Average Final Compensation:
Members Age:
18. Member's Certification
Member's Signature:
Date:
The individual whose name is signed above appeared before me, acknowledged the signature to be his/hers, and having been duly sworn
by me, made an oath that the statements are true.
PART F. NOTARY PUBLIC
Notary Public:
o Deferred Service
RRS OFFICE USE ONLY
Board of Trustees Agenda:
16. Address:
State of:
City/County of:
on:
PART E. CERTIFICATION
I hereby certify that: 1) all of the foregoing facts are correct, 2) I have read and understand the service retirement information in the Members Handbook, 3) I have
satisfied the retirement eligibility requirements set forth in the City of Richmond Code Chapter 78 and 4) I fully understand Article IX of Chapter 78 of the City of
Richmond Code governing the payment options available to me. I further understand that I must 1) submit proof of my birth date, 2) submit proof of my beneficiary's
birth date, (if I elect a survivorship option), 3) enroll in a health/dental insurance program, if eligible, within 30 days from the date of my retirement, or be subject to the
City's re-enrollment provisions, 4) enroll in the direct deposit program to receive my benefits and 5) submit my application within 60 – 90 days of my requested
retirement date; and if I submit my application outside that window, I must make a written request for an exception to this policy. I further understand that if an
exception is granted, my initial pension payment may be delayed up to 90 days. Additionally, I agree that I (or my estate) will repay any excess payment of benefits to
which I am not entitled.
Notary Registration Number:
PART C. BENEFIT PAYMENT OPTION
o Deferred Early Service
o Deferred Early Service (DC Plan)
(Choose One)
PART A. MEMBER INFORMATION
please type or print in ink
9. Retirement Date:
8. Job Title:
7. Department:
o Service (Normal Retirement)
RETIREMENT APPLICATION
730 East Broad Street
Suite 900
Richmond, VA 23219
RICHMOND RETIREMENT SYSTEM
www.richmondgov.com/retirement
Phone 804.646.5958
Fax 804.646.5299
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Retirement Application Form

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Completed 16 July 2020

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