Fillable Service Retirement Election Application (California)

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Service Retirement Election Application (California)

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The Service Retirement Election Application (California) form is 16 pages long and contains:

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  • 279 other fields

Country of origin: US
File type: PDF

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Please provide your
name as it appears on
your Social Security card.
Section 2
Information About Your Retirement
Last Day on Payroll (mm/dd/yyyy) Your Retirement Date (mm/dd/yyyy)
Employer Full Name
Full Position Title
Temporary Annuity
Choosing to receive temporary annuity payments permanently reduces your retirement benefit. Refer to
the Temporary Annuity publication (PUB 13) before making this choice.
To elect to receive a temporary annuity payment, 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 or after January 1, 2002, and have CalPERS service coordinated
with Social Security. I elect to receive temporary annuity until age in the amount
of $ per month. I certify this amount does not exceed my estimated Social Security
benefit at age .
Other California Public Retirement Systems
If you are a member of a defined benefit plan with a California public retirement system other than CalPERS,
please complete the following:
Name of Reciprocal System
Last Day of Employment With Reciprocal System (mm/dd/yyyy) Retirement Date With Reciprocal System (mm/dd/yyyy)
Please enter the last day
you were on payroll with a
CalPERS-covered employer.
In the event of your death,
any outstanding temporary
annuity payments will be
paid in a lump sum to a
beneficiary. Complete your
beneficiary information
in Section 4c.
(62 to 70)
Dollars(59½ or whole age 60 to 68)
Your Name (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Address
City State ZIP Country
Birth Date (mm/dd/yyyy) Daytime Phone Alternate Phone
Email Address
Dollars
Section 1
Information About You
Please do not mail or deliver your application to CalPERS more than 120 days before your retirement date.
For detailed instructions on how to complete this form, please refer to the publication Service Retirement Election
Application (PUB 43).
( )
( )
PERS-BSD-369-S (12/21) Page 1 of 10
888 CalPERS (or 888-225-7377)
•
TTY: (877) 249-7442
Service Retirement Election Application
Section 3
Select Your Retirement Payment Option
Choose one of the following retirement payment options.
c
Unmodified Allowance
There is no beneficiary designation with this option. Skip to Section 5.
c
Return of Remaining
Contributions Option 1
Complete your beneficiary designation in Section 4c.
c
100 Percent Beneficiary Option 2
Complete your beneficiary designation in Sections 4a and 4c.
c
100 Percent Beneficiary Option 2
with Benefit Allowance Increase
Complete your beneficiary designation in Section 4a.
c
50 Percent Beneficiary Option 3
Complete your beneficiary designation in Sections 4a and 4c.
c
50 Percent Beneficiary Option 3
with Benefit Allowance Increase
Complete your beneficiary designation in Section 4a.
Flexible Beneficiary Option 4
Choose one of the options below.
c
Specific Percentage
Complete your beneficiary designation in Section 4b.
c
Specific Dollar Amount
Complete your beneficiary designation in Section 4b.
Court-Ordered Community
Property Option 4
Provide your former spouse/partner’s information and choose
one of the options below for your share of the benefit.
Former Spouse/Former Registered Domestic Partner (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
c
Unmodified Allowance
There is no beneficiary designation with this option. Skip to Section 5.
c
Return of Remaining
Contributions Option 1
Complete your beneficiary designation in Section 4c.
c
Specific Percentage
Complete your beneficiary designation in Section 4b.
c
Specific Dollar Amount
Complete your beneficiary designation in Section 4b.
Your retirement payment
option choice becomes
irrevocable 30 days
from the date your first
retirement check is issued
unless you have a future
qualifying event, such as
the death of a beneficiary.
If you are required by a
court order to designate
your nonmember spouse
or partner for an ongoing
monthly benefit, choose
one of the Court-Ordered
Community Property
Option 4 options for your
share of the benefit.
Section 4a
Complete Your Beneficiary Information – Ongoing Monthly Benefit
If you chose one of the following options, name one beneficiary to receive the ongoing monthly benefit
upon your death.
•
100 Percent Beneficiary Option 2
•
100 Percent Beneficiary Option 2 with Benefit Allowance Increase
•
50 Percent Beneficiary Option 3
•
50 Percent Beneficiary Option 3 with Benefit Allowance Increase
Name (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Birth Date (mm/dd/yyyy) Gender Relationship to You
Address
City State ZIP Country
The beneficiary you name
in this section becomes
irrevocable 30 days
from the date your first
retirement check is issued
unless you have a future
qualifying event, such as
the death of a beneficiary.
c
Male
c
Female
c
Nonbinary
PERS-BSD-369-S (12/21) Page 2 of 10
Your Name Social Security Number or CalPERS ID
Put your name and Social
Security number or CalPERS ID
at the top of every page.
Any beneficiary you name
in this section becomes
irrevocable 30 days
from the date your first
retirement check is issued
unless you have a future
qualifying event, such as
the death of a beneficiary.
Complete all fields for each
beneficiary and specify the
percentage or dollar
amount. If you name more
than one beneficiary and
you want your beneficiaries
to receive an equal share
of your benefits, do not
specify a dollar or
percentage of benefit.
Section 4b
Complete Your Beneficiary Information – Specific Percentage or
Specific Dollar Amount
If you chose one of the following options, name one or more beneficiaries to receive a specific percentage
or dollar amount of your Unmodified Allowance upon your death.
•
Flexible Beneficiary Option 4/Specific Percentage or Specific Dollar Amount
•
Court-Ordered Community Property Option 4/Specific Percentage or Specific Dollar Amount
If you want to name more
than four beneficiaries, call
us toll free at 888 CalPERS
(or 888-225-7377).
Name (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Birth Date (mm/dd/yyyy) Gender Relationship to You
Dollar Amount Percent of Benefit
Address
City State ZIP Country
c
Male
c
Female
c
Nonbinary
$ %
Name (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Birth Date (mm/dd/yyyy) Gender Relationship to You
Dollar Amount Percent of Benefit
Address
City State ZIP Country
c
Male
c
Female
c
Nonbinary
$ %
Name (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Birth Date (mm/dd/yyyy) Gender Relationship to You
Dollar Amount Percent of Benefit
Address
City State ZIP Country
c
Male
c
Female
c
Nonbinary
$ %
Name (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Birth Date (mm/dd/yyyy) Gender Relationship to You
Dollar Amount Percent of Benefit
Address
City State ZIP Country
c
Male
c
Female
c
Nonbinary
$ %
PERS-BSD-369-S (12/21) Page 3 of 10
Your Name Social Security Number or CalPERS ID
Put your name and Social
Security number or CalPERS ID
at the top of every page.
Section 4c
Complete Your Beneficiary Information – Return of Remaining Contributions
If you want to name
separate beneficiaries
for the balance of your
remaining contributions
and/or temporary annuity
balance, call us toll
free at 888 CalPERS
(or 888-225-7377).
If you name more than
one beneficiary and you
want your beneficiaries to
receive an equal share of
your benefits, do not
specify a percentage
of benefit.
If you want to name more
than four beneficiaries, call
us toll free at 888 CalPERS
(or 888-225-7377).
If you chose one of the following options, name one or more beneficiaries to receive a return of any
of your remaining member contributions. You can change this beneficiary designation at any time.
•
Return of Remaining Contributions Option 1
•
100 Percent Beneficiary Option 2
•
50 Percent Beneficiary Option 3
•
Temporary Annuity (remaining balance upon your death)
•
Court-Ordered Community Property Option 4/Return of Remaining Contributions Option 1
Name (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Birth Date (mm/dd/yyyy) Relationship to You Priority Percent of Benefit
Address
City State ZIP Country
c
Primary
c
Secondary
Name (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Birth Date (mm/dd/yyyy) Relationship to You Priority Percent of Benefit
Address
City State ZIP Country
Name (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Birth Date (mm/dd/yyyy) Relationship to You Priority Percent of Benefit
Address
City State ZIP Country
Name (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Birth Date (mm/dd/yyyy) Relationship to You Priority Percent of Benefit
Address
City State ZIP Country
c
Primary
c
Secondary
c
Primary
c
Secondary
c
Primary
c
Secondary
%
%
%
%
PERS-BSD-369-S (12/21) Page 4 of 10
Your Name Social Security Number or CalPERS ID
Put your name and Social
Security number or CalPERS ID
at the top of every page.
Section 5
Retired Death Benefit – Beneficiary Designation
Name one or more beneficiaries to receive the Retired Death Benefit upon your death. The amount payable
is based on your employer's contract with us. You can change this beneficiary designation at any time.
If you name more than
one beneficiary and you
want your beneficiaries to
receive an equal share of
your benefits, do not
specify a percentage
of benefit.
If you last worked with
another California retirement
system that provides a
similar death benefit, the
CalPERS Retired Death
Benefit is not paid.
If you want to name more
than four beneficiaries, call
us toll free at 888 CalPERS
(or 888-225-7377).
Name (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Birth Date (mm/dd/yyyy) Relationship to You Priority Percent of Benefit
Address
City State ZIP Country
c
Primary
c
Secondary
%
Name (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Birth Date (mm/dd/yyyy) Relationship to You Priority Percent of Benefit
Address
City State ZIP Country
c
Primary
c
Secondary
%
Name (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Birth Date (mm/dd/yyyy) Relationship to You Priority Percent of Benefit
Address
City State ZIP Country
c
Primary
c
Secondary
%
Name (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Birth Date (mm/dd/yyyy) Relationship to You Priority Percent of Benefit
Address
City State ZIP Country
c
Primary
c
Secondary
%
PERS-BSD-369-S (12/21) Page 5 of 10
Your Name Social Security Number or CalPERS ID
Put your name and Social
Security number or CalPERS ID
at the top of every page.
Section 6
Survivor Continuance Information
1. Were you married or in a registered domestic partnership at least one year prior to your retirement date?
c
No
c
Yes, provide:
Name of Spouse/Registered Domestic Partner (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Birth Date (mm/dd/yyyy) Date of Marriage or Registered Domestic Partnership (mm/dd/yyyy)
Address
City State ZIP Country
2. Do you have any natural or legally adopted unmarried children under age 18?
c
No
c
Yes, provide:
Name of Child (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Birth Date (mm/dd/yyyy)
Address
City State ZIP Country
Name of Child (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Birth Date (mm/dd/yyyy)
Address
City State ZIP Country
3. Do you have any unmarried children who were disabled prior to their 18th birthday and who are still
disabled?
c
No
c
Yes, provide:
Name of Child (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Birth Date (mm/dd/yyyy)
Address
City State ZIP Country
Name of Child (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Birth Date (mm/dd/yyyy)
Address
City State ZIP Country
Section 6 continues on page 7
See Survivor Continuance
instructions in the publication
Service Retirement Election
Application (PUB 43) to
learn about eligibility
requirements for this benefit.
PERS-BSD-369-S (12/21) Page 6 of 10
Your Name Social Security Number or CalPERS ID
Put your name and Social
Security number or CalPERS ID
at the top of every page.
Section 6, continued
Survivor Continuance Information, continued
Dollars
Federal Income Tax information:
c
Do not withhold federal income tax.
c
Withhold federal income tax based on the tax tables for:
c
A married individual with tax withholding allowances.
c
A single individual with tax withholding allowances.
In addition to the amount withheld based on the tax tables, withhold $ per month.
c
A married individual, but withhold at the higher single rate with tax withholding allowances.
State Income Tax information:
c
Do not withhold State of California income tax.
c
Withhold State of California income tax in the amount of $ per month.
c
Withhold State of California income tax based on the tax tables for:
c
A married individual with tax withholding allowances.
c
A single individual with tax withholding allowances.
c
A head of household individual with tax withholding allowances.
In addition to the amount withheld based on the tax tables, withhold $ per month.
c
Withhold State of California income tax in the amount of 10 percent of the federal income tax
withholding amount.
Please choose only one.
Number
Number
Number
Number
Number
Number
Dollars
Dollars
Section 7 Tax Withholding Election
Please choose only one.
State withholding
is optional for
out-of-state residents.
4. Are your parents dependent upon you for one-half of their support?
c
No
c
Yes, provide:
Name of Parent (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
Birth Date (mm/dd/yyyy)
Address
City State ZIP Country
PERS-BSD-369-S (12/21) Page 7 of 10
Your Name Social Security Number or CalPERS ID
Put your name and Social
Security number or CalPERS ID
at the top of every page.
Section 8 Direct Deposit Information
Section 9 CalPERS Health Coverage
I certify I am entitled to receive this payment. I authorize my retirement payment to be sent to my financial
institution and deposited to my designated account. I understand CalPERS does not accept a prepaid debit card
as a payment option. I authorize amounts transferred after my death or transmitted in error to be debited from
my account. Additionally, I certify that the funds received are not deposited to an account that is subject to being
transferred to a foreign financial institution.*
If you are currently enrolled in your own right for CalPERS health benefits, you can continue your health
enrollment into retirement with no break in coverage.
If you do not want health coverage, you must cancel retiree health coverage by declining coverage below.
You may be eligible to enroll in health coverage during the next Open Enrollment period.
c
I decline continuation of my CalPERS health coverage into retirement.
*To comply with NACHA
regulations regarding
international ACH
transactions, CalPERS
will not accept requests
for electronic fund transfers
(EFT) in association with
financial institutions outside
of the territorial jurisdiction
of the United States. (The
territorial jurisdiction of the
United States includes all
50 states, U.S. territories,
U.S. military bases, and
U.S. embassies in foreign
countries.) If your entire
benefit allowance will be
received by a financial
institution outside the
territorial jurisdiction of the
U.S., you will be issued a
paper check in lieu of the EFT.
** Trust Account
You also need to
complete and submit a
Request for Payment of
Monthly Allowance to a
Trust form available at
www.calpers.ca.gov
and a copy of the
Certification of Trust from
your trust document.
c
Checking
c
Savings
c
Joint
c
Trust Account **
Routing Number (nine digits) Account Number
If you are authorizing your payment to your savings account or do not have pre-printed, personalized checks,
please have your financial institution complete the information below.
Please use tape to attach your voided, pre-printed personalized check. (Do not staple or paper clip. No deposit slips.)
Name of Financial Institution Branch Phone Number
Address
City State ZIP
You confirm the identity of the above-named payee and the account number. As a representative of the above-named
financial institution, you certify the financial institution agrees to receive and deposit the payment identified above.
Signature of Representative Print Representative’s Name Date (mm/dd/yyyy)
( )
You can view and print your benefit statement, which shows your total deposit amount, including any
reimbursements or authorized deductions, at my.calpers.ca.gov.
Information About Joint Account Holder, if applicable
Name Social Security Number or CalPERS ID
Address Daytime Phone
City State ZIP
( )
PERS-BSD-369-S (12/21) Page 8 of 10
Your Name Social Security Number or CalPERS ID
Put your name and Social
Security number or CalPERS ID
at the top of every page.
You must review and sign this acknowledgment if you are married or in a registered domestic partnership and
you name someone other than your spouse or domestic partner as a beneficiary to receive an ongoing monthly
benefit or any lump-sum benefits that may be payable upon your death.
Member Acknowledgment
I understand that if I am married or in a registered domestic partnership, my spouse or domestic partner
may have community property rights in one or more of the following benefits (if applicable):
•
The monthly option benefit that continues following a member’s death;
•
The return of any remaining member contributions; and/or
•
The Retired Death Benefit.
If I name someone other than my spouse or domestic partner as my beneficiary for some or all of these benefits
and I die before my spouse or domestic partner, he or she may still be entitled to receive his or her community
property share of the benefit(s). If I name one or more other individuals as my beneficiary(ies) to receive a benefit
listed above, and my spouse or domestic partner does not consent at this time by signing below, CalPERS will
award 50 percent of the community property share of such benefit to my spouse or domestic partner in the
event of my death unless he or she waives his or her community property interest in such benefit at the time the
benefit becomes payable, and CalPERS will award the remaining 50 percent of the community property share,
plus any separate property share, of such benefit to the named beneficiary(ies).
Your Signature Date (mm/dd/yyyy)
Spouse’s or Registered Domestic Partner’s Consent
I hereby voluntarily and irrevocably consent to each of the beneficiary designation(s) by my spouse/registered
domestic partner in this application. I acknowledge and understand that I am not obligated to consent and, if I
do consent, and my spouse or registered domestic partner dies before me and has named a beneficiary other
than me, some or all of the following benefits will be paid to a beneficiary other than me in accordance with the
beneficiary designation(s):
•
The monthly option benefit that continues following a member’s death;
•
The return of any remaining member contributions; and/or
•
The Retired Death Benefit.
I understand that I may have community property or other rights in these benefits, and I hereby voluntarily waive
and release any rights I may have to these benefits. I understand that I do not have to sign this consent and that
if I do sign my consent is irrevocable. I acknowledge that I have received a complete explanation of each benefit
listed above (if applicable), and I have had the opportunity to consult with an attorney or other professional
concerning this waiver.
Your Spouse’s or Domestic Partner’s Signature Date (mm/dd/yyyy)
Section 10 Spousal Consent to Beneficiary Designation
Your signature must be
notarized by a notary public
or witnessed by a
CalPERS representative.
Your spouse or registered
domestic partner should
sign this consent if he or
she consents to each of your
beneficiary designations
after reviewing this section.
His or her signature must be
notarized or witnessed by a
CalPERS representative.
PERS-BSD-369-S (12/21) Page 9 of 10
Put your name and Social
Security number or CalPERS ID
at the top of every page.
Your Name Social Security Number or CalPERS ID
Section 11 Signatures and Notary or Witness Acknowledgment
This section must
be completed or
your application will
be returned.
Your signature and your
spouse’s or registered
domestic partner’s signature
must be notarized by a
notary public or witnessed
by a CalPERS representative.
I certify, under the penalty of perjury, that the information submitted hereon is true and correct to the best of
my knowledge. I understand that I only have 30 days from the issuance of my first retirement benefit
check to cancel or make any changes to this application. If I seek post-retirement CalPERS employment,
I understand I must read the publication A Guide to CalPERS Employment After Retirement (PUB 33), which
contains information about the requirements for such employment.
Are you legally married or do you have a state-recognized registered domestic partner?
c
Yes
c
No
If no, please indicate:
c
Never Married or in Domestic Partnership
c
Divorced, Annulled, or Domestic Partnership Terminated
c
Widowed
If you answered yes above, your spouse or registered domestic partner must sign this application unless you
have elected 100 Percent Beneficiary Option 2 or 100 Percent Beneficiary Option 2 with Benefit Allowance
Increase as your retirement payment option, and you designated your spouse or registered domestic partner
as the beneficiary, and you designated him or her as the sole primary beneficiary of any lump-sum benefits.
Otherwise, you must complete and submit the Justification for Absence of Spouse’s or Registered Domestic
Partner’s Signature form.
Your Signature Date (mm/dd/yyyy)
Your Spouse’s or Domestic Partner’s Signature Date (mm/dd/yyyy)
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.
State of California, County of On
before me, personally appeared
, 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.
Notary Seal
Witness my hand and official seal or authorized CalPERS representative signature.
Signature of Notary or CalPERS Representative Position Title Date (mm/dd/yyyy)
Print Name CalPERS Office (if applicable)
Date
Name of Notary/Witness
Mail to:
CalPERS Retirement Benefit Services Division • P.O. Box 942711, Sacramento, California 94229-2711
PERS-BSD-369-S (12/21) Page 10 of 10
Your Name Social Security Number or CalPERS ID
Put your name and Social
Security number or CalPERS ID
at the top of every page.
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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Service Retirement Election Application (California)

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Completed 6 July 2022

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