Fillable StanCERA Service Retirement Application Checklist

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StanCERA Service Retirement Application Checklist

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P (209) 525-6393 | F (209) 558-4976 | www.stancera.org
832 12th Street, Suite 600, Modesto, CA 95354 | P.O. Box 3150, Modesto, CA 95353
StanCERA Service Retirement Application Checklist
This checklist contains the forms and documents that you will need to provide before your application
is considered complete. Once all these items have been submitted, in their entirety, your application
for retirement will be processed. StanCERA can accept your retirement application no more than 60
days prior to your chosen date of retirement.
If you have any questions, please contact StanCERA at (209) 525-6393 or retirement@stancera.org.
SUBMITTED FOR:
✓
✓
You:
Primary
Beneficiary:
REQUIRED DOCUMENTS
Copy of Certified Birth Certificate, if not on file
Copy of Driver’s License, Passport, or other form of legal identification
Copy of Marriage or Domestic Partnership Registration Certificate, if
applicable
Social Security Benefit Estimate, if applicable
Copy of finalized divorce documents, if applicable
FORMS INCLUDED WITH APPLICATION
Completed Application for Service Retirement
Retiree Tax Withholding Election Form – W4-P
Authorization for Automatic Deposit
Other than Spouse or Domestic Partner Written Nomination of Beneficiary
$5,000 Death Benefit
Lump Sum Final Payment Upon Death Written Nomination of Beneficiary
Normal Retirement Age & Post Retirement Employment Questionnaire
Social Security Modification Option Acknowledgement
RESCO Information Request
Medical, Dental, & Vision Information Request
StanCERA Service Retirement Application
Information Packet
StanCERA recommends that you give as much notice as possible of your intended retirement
date, preferably the entire sixty (60) days prior to retirement allowed by law, in the event there
are discrepancies in your account.
There are a few items that you will need to provide to StanCERA and important factors to
consider:
• Your date of retirement cannot be effective until the day after your last day on paid
status with your employer (you cannot be paid by your employer for your date of
retirement);
• Your retirement effective date cannot be earlier than the date StanCERA receives your
application;
• You must notify your employer of your intent to retire and the effective date of your
retirement;
• Incremental age adjustment makes a difference in your benefit. For each quarter year
increase in age the benefit will increase, up to a maximum age base on specific Tiers for
both General and Safety plans;
• The annual cost of living (COLA), as a retiree, is effective on April 1
st
of each year. If
you retire prior to April 1
st
, you will receive the appropriate cost of living
increase/decrease provided to the retirees that year; and
• If you are a reciprocal member of another public agency, you are responsible to provide
all necessary documents to the other system(s) and must use the same retirement date
with all systems.
REQUIRED DOCUMENTS TO BE SUBMITTED
The following documents are required in order to complete the application process. To avoid
delay, you must provide photocopies of these documents to StanCERA with your completed
application packet:
▪ Member’s Certified Birth Certificate (if not on file)
▪ Member’s Driver’s License, Passport, or other form of legal identification
▪ Certified Marriage or Domestic Partner Registration Certificate (if applicable)
▪ Primary Beneficiary’s Certified Birth Certificate (if not on file)
▪ Primary Beneficiary’s Driver’s License, Passport, or other form of legal identification
▪ Social Security Benefit Estimate (if applicable)
If divorced during StanCERA Membership:
▪ Court endorsed Dissolution of Marriage/Partnership Judgment and Marital Settlement
Agreement, in their entirety (if not on file)
▪ Domestic Relations Order, if applicable (if not on file)
Page 2 of 34
Your Service Retirement Application is not considered complete until all required documents
have been received.
REQUIRED FORMS TO BE SUBMITTED:
The following forms are included in the application packet and must be completed and
submitted:
▪ Original, completed StanCERA Service Retirement Application
▪ Required Documents Listed
▪ Written Nomination of Beneficiary – Other than Spouse or Domestic Partner (if applicable)
▪ Retiree Tax Withholding Election Form – W4-P
▪ $5,000 Death Benefit Form (if Applicable)
▪ Written Nomination of Beneficiary – Final Lump Sum Payment Upon Death
▪ Authorization Agreement for Automatic Deposit
▪ Normal Retirement Age and Post Retirement Questionnaire
▪ Social Security Modification Option Acknowledgement (if applicable)
▪ RESCO/RESCO Insurance/Stanislaus County Risk Management Acknowledgement
FORMS EXPLAINED:
Retiree Tax Withholding Election Form – W4-P:
Complete this form by checking at least one box each for Federal and California State tax
withholding. A new tax withholding form may be completed as often as you wish throughout
your retirement.
Authorization Agreement for Automatic Deposit:
The completion of this form authorizes StanCERA to directly deposit your monthly benefits into
the bank account of your choice on the first federal banking day of the month with a
remittance advice mailed to you on a monthly basis. In order to verify bank routing and
account numbers, the following is required:
▪ For Checking accounts, a voided check or bank documentation is required. Deposit slips
are not accepted.
▪ For Savings accounts, please include bank documentation
Any new election or changes to automatic deposit will result in a physical check being issued for
the first month, with automatic deposit beginning the next month.
Beneficiaries:
For most members, the beneficiary is their qualified spouse or registered domestic partner. An
eligible spouse or domestic partner is a person you have been married or registered to for at
least one year prior to retiring. If a member marries or remarries after retirement, the new
spouse or partner is not eligible for a continuing retirement benefit.
Written Nomination of Beneficiary – Other than Spouse or Domestic Partner
If you designate your spouse/partner as your Primary Beneficiary and plan to choose the
60% Continuance Option, you will need to complete this form. In the unlikely event your
spouse/partner pre-deceases you, any remaining contributions on account will be
returned to this named beneficiary upon your death.
Page 3 of 34
$5,000 Death Benefit
When a retiree passes away, a death benefit is paid to the designated beneficiary upon
presentation of a photocopy of a valid, final, certified death certificate and a completed
distribution packet to StanCERA. This is not a life insurance benefit and is taxable
income to the designated beneficiary. You are permitted to change this beneficiary
throughout your retirement.
Exceptions to the burial allowance:
• In cases of reciprocity, if the retiree was last employed with another system, the
benefit will be paid by the last system.
• One death benefit is paid and applies to the original retiree.
Written Nomination of Beneficiary – Final Benefit Payment Upon Death
When a retiree passes away, there may be a final payment to be made to the retiree’s
estate. In order for this to be a smooth process, the retiree may name a beneficiary for
this final lump sum payment.
Normal Retirement Age and Post Retirement Questionnaire:
PEPRA and the IRS have established certain guidelines regarding the Normal Retirement Age
and Post Retirement Employment. This questionnaire will assist members in determining if they
qualify to return to part-time employment post retirement.
Social Security Modification Option:
The Social Security Modification (Income Leveling) is a popular, yet complex option for
members under age 62. Please read this form carefully prior to deciding if this is the right option
for you. This form must be completed if you are under 62 and wish to take the Social Security
Modification Option.
RESCO Information Request:
Membership with Retired Employees of Stanislaus County Organization (RESCO), an
independent organization, is voluntary. If you are taking advantage of optional insurance
coverages offered through RESCO, membership is required. As a courtesy, StanCERA will
forward your request for membership information as part of the retirement application process.
Future inquiries are the responsibility of the retiree.
Medical, Dental, and Vision Information Request:
Insurance coverage is an important part of the decision making when it comes to retiring. As a
courtesy, StanCERA will forward your request for information on available plans to Pacific
Group Agency and/or Stanislaus County as part of the retirement application process.
However, please note that retirees are not limited to these individual plans. You are welcome to
explore the options available through Covered California or with an individual broker.
Additional Information:
The following is a list of additional materials included in your packet, which you may find helpful:
• Taxation of Retirement Benefits
• Employment after Retirement
• Cost of Living Adjustment
• PEPRA and IRS Decision Tree
Page 4 of 34
RETIREE PAYROLL:
StanCERA attempts to pay retirees within sixty (60) days after final payroll date. As a guide,
the StanCERA Retirement Pay Schedule is included in the packet.
Your monthly retirement allowance is paid on the first federal banking day of each month (not
including weekends and holidays) for the month prior. The monthly retirement allowance check
(or advice notice if utilizing direct deposit) is mailed to your location of choice: home, post office
box, etc.
Depending on mail service, your check or advice notice may arrive anywhere from two (2) to
seven (7) days after it is mailed. If you are away on vacation, the mail carrier may not deliver
your check or advice notice. If your check is lost in the mail, StanCERA cannot request a
replacement check for ten (10) business days.
StanCERA strongly recommends signing up for automatic deposit with the financial institution of
your choice.
It is your responsibility to keep your address current with StanCERA. Failure to maintain a
current address will result in returned mail to StanCERA and may result in a suspension of your
monthly retirement benefit. The U.S. Postal Service does not forward StanCERA
correspondence.
All change forms need to be submitted to StanCERA by the 10
th
of each month to ensure the
change will be effective by the following benefit payment.
WITHDRAWAL OF RETIREMENT APPLICATION:
A Service Retirement Application may be withdrawn, or the date of retirement changed, upon
submitting a written request to StanCERA prior to the effective date of retirement. A withdrawal
of application or change in retirement date will not serve to automatically reinstate your status
as an employee. This is a separate issue between you and your employer, and the outcome
will have no effect on your eligibility to receive retirement benefits. Members who withdraw their
retirement application will be required to repeat the process and complete another packet when
they are ready to begin the process in the future.
FINAL APPOINTMENT:
Upon receipt of your application, with the completed forms, all required documents, and your
final payroll details, StanCERA will calculate your retirement benefit. You will be required to
finalize your beneficiary designation and benefit option selection with StanCERA staff one final
time after your date of retirement, before your first benefit payment is issued to choose your
retirement option and to sign final documents.
Page 5 of 34
2021 StanCERA Retirement Pay Schedule
StanCERA uses the County’s payroll as a guideline when determining the first anticipated pay
date of retirees. Effective retirement date is the day after last day of compensation by employer.
StanCERA attempts to pay retirees 60 days from last active pay date.
Employment Dates:
Final Active
Employee Pay
Date
Anticipated First
Retiree Pay Date
December 19, 2020
To
January 1, 2021
January 13, 2021
March 1, 2021
January 2, 2021
To
January 15, 2021
January 27, 2021
April 1, 2021
January 16, 2021
To
January 29, 2021
February 10, 2021
April 1, 2021
January 30, 2021
To
February 12, 2021
February 24, 2021
May 3, 2021
February 13, 2021
To
February 26, 2021
March 10, 2021
May 3, 2021
February 27, 2021
To
March 12, 2021
March 24, 2021
June 1, 2021
March 13, 2021
To
March 26, 2021
April 7, 2021
June 1, 2021
March 27, 2021
To
April 9, 2021
April 21, 2021
July 1, 2021
April 10, 2021
To
April 23, 2021
May 5, 2021
July 1, 2021
April 24, 2021
To
May 7, 2021
May 19, 2021
August 2, 2021
May 8, 2021
To
May 21, 2021
June 2, 2021
August 2, 2021
May 22, 2021
To
June 4, 2021
June 16, 2021
August 2, 2021
June 5, 2021
To
June 18, 2021
June 30, 2021
September 1, 2021
June 19, 2021
To
July 2, 2021
July 14, 2021
September 1, 2021
July 3, 2021
To
July 16, 2021
July 28, 2021
October 1, 2021
July 17, 2021
To
July 30, 2021
August 11, 2021
October 1, 2021
July 31, 2021
To
August 13, 2021
August 25, 2021
November 1, 2021
August 14, 2021
To
August 27, 2021
September 8, 2021
November 1, 2021
August 28, 2021
To
September 10, 2021
September 22, 2021
December 1, 2021
September 11, 2021
To
September 24, 2021
October 6, 2021
December 1, 2021
September 25, 2021
To
October 8, 2021
October 20, 2021
December 1, 2021
October 9, 2021
To
October 22, 2021
November 3, 2021
January 3, 2022
October 23, 2021
To
November 5, 2021
November 17, 2021
January 3, 2022
November 6, 2021
To
November 19, 2021
December 1, 2021
February 1, 2022
November 20, 2021
To
December 3, 2021
December 15, 2021
February 1, 2022
December 4, 2021
To
December 17, 2021
December 29, 2021
March 1, 2022
Page 6 of 34
Service
Retirement
Application
Page 7 of 34
Application for Service Retirement
Type or print in ink.
SECTION 1: RETIREE INFORMATION
FIRST NAME:
MI:
LAST NAME:
SEX:
EMPLOYEE ID NUMBER:
MAILING ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME PHONE:
CELL PHONE:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
E-MAIL ADDRESS:
MOTHER’S MAIDEN NAME:
In accordance with provisions of the County Employees’ Retirement Act of 1937 and the Bylaws governing the
Association, I hereby make application for retirement from active/deferred service as:
SECTION 2: EMPLOYMENT AND RETIREMENT INFORMATION
LAST STANCERA EMPLOYER:
DEPARTMENT:
POSITION HELD:
LAST DATE OF EMPLOYMENT WITH STANCERA:
PLANNED DATE OF RETIREMENT:
SECTION 3: RECIPROCITY, IF APPLICABLE
If applicable, all documents submitted to each retirement system must declare same retirement date.
Reciprocal Agency:
Planned Date of Retirement:
Are you currently employed with reciprocal agency? Yes No
Do you have a higher salary with reciprocal agency? Yes No
SECTION 4: SOCIAL SECURITY MODIFICATION OPTION, IF APPLICABLE (must be under age 62)
Requesting Social Security Modification Option. (GC §31810)? Yes No
If Yes, estimated Social Security amount at age 62:
SECTION 5: MARRIAGE/DOMESTIC PARTNERSHIP
Are you legally married or have registered domestic partner? Yes No
Date of marriage/registration:
Spouse/Partner’s name:
Social Security number:
Birthdate:
Were you divorced while employed? Yes No
Date of Divorce:
SECTION 6: DEPENDENT STATUS
Do you have any minor children? Yes No
CHILD’S NAME:
SEX:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
RELATIONSHIP:
Page 8 of 34
SECTION 7: PRIMARY BENEFICIARY INFORMATION
PRIMARY BENEFICIARY
FIRST NAME:
MI:
LAST NAME:
SEX:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
BENEFIT PERCENT:
MAILING ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME PHONE:
CELL PHONE:
E-MAIL ADDRESS:
RELATIONSHIP:
IF MARRIED/REGISTERED DOMESTIC PARTNER STOP HERE. CONTINUE IF DESIGNATING MULTIPLE BENEFICIARIES.
(Continuance options are available to one named beneficiary only.)
BENFICIARY #2
PRIMARY
FIRST NAME:
MI:
LAST NAME:
SEX:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
BENEFIT PERCENT:
MAILING ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME PHONE:
CELL PHONE:
E-MAIL ADDRESS:
RELATIONSHIP:
BENFICIARY #3 PRIMARY
FIRST NAME:
MI:
LAST NAME:
SEX:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
BENEFIT PERCENT:
MAILING ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME PHONE:
CELL PHONE:
E-MAIL ADDRESS:
RELATIONSHIP:
SECTION 8: REQUIRED SIGNATURES
Pursuant to StanCERA Bylaw Article 5.1, application for service retirement shall be deemed complete when all required documents and
forms have been received. Applications shall not be accepted more than 60 days prior to date of retirement.
Applicant Signature:
Printed Name:
Date:
Spouse/Partner Signature:
Printed Name:
Date:
Page 9 of 34
Retiree Tax Withholding Election Form – W4-P
Type or print in ink.
RETIREE INFORMATION
FIRST NAME:
MI:
LAST NAME:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
NEW ADDRESS?
YES NO
MAILING ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME PHONE:
CELL PHONE:
EMAIL ADDRESS:
FEDERAL WITHHOLDING ELECTION
OPTION 1:
I want federal income tax withheld from my monthly retirement benefit as follows:
Marital Status:
Single
Married
Number of withholding allowances (enter “0” of zero):
I want the following amount withheld in addition to the federal tax table:
$
OPTION 2:
I do not want federal income tax withheld from my monthly retirement benefit.
(Not available to
U.S. Citizens living in a foreign country)
CALIFORNIA STATE WITHHOLDING ELECTION
OPTION 1:
I want California State income tax withheld from my monthly retirement benefit as follows:
Marital Status:
Single
Married
Number of withholding allowances (enter “0” of zero):
I want the following amount withheld in addition to the California tax table:
$
OPTION 2:
I do not want California State tax withheld from my monthly retirement benefit.
OPTION 3:
I want the designated flat amount withheld from each monthly retirement benefit.
$
AUTHORIZATION
Any prior Federal or California State withholding form on file with StanCERA is hereby revoked. I further
understand that any request received by StanCERA on or before the 10
th
of the month, will become effective the
next payroll process.
Retiree Signature:
Printed Name:
Date:
Page 10 of 34
PAGE INTENTIONALLY LEFT BLANK
Page 11 of 34
Authorization Agreement for Automatic Deposit
Type or print in ink.
SECTION 1: PAYEE INFORMATION
FIRST NAME:
MI:
LAST NAME:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
NEW ADDRESS?
YES
NO
MAILING ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME PHONE:
CELL PHONE:
EMAIL ADDRESS:
SECTION 2: FINANCIAL INSTITUTION INFORMATION
NAME OF FINANCIAL INSTITUTION:
PHONE NUMBER:
ADDRESS:
CITY:
STATE:
ZIP CODE:
ROUTING NUMBER:
ACCOUNT NUMBER:
ACCOUNT INFORMATION:
TYPE OF ACCOUNT:
Checking Account: Attach voided check or bank documentation with routing and account number (deposit slips not accepted).
Savings Account: Attach bank documentation with routing and account number.
IMPORTANT PAYROLL INFORMATION:
All payroll changes must be submitted prior to the 10th of every month, to become effective the following
month. Any new election or changes to automatic deposit will result in a physical check being issued for the
first month, with automatic deposit beginning the next month.
SECTION 3: AUTHORIZATION
I hereby authorized the Stanislaus County Employees’ Retirement Association to initiate, if necessary, debit entries and
adjustments for any credit entries in error to my account, and the depository named above to credit and/or debit the same
to such account. The U.S. Postal Service does not forward StanCERA correspondence. Failure to maintain a current
U.S. postal address or, mail returned to StanCERA, may result in a suspension of my direct deposit.
Retiree Signature:
Printed Name:
Date:
Page 12 of 34
PAGE INTENTIONALLY LEFT BLANK
Page 13 of 34
Type or print in ink.
SECTION 1: RETIREE INFORMATION
FIRST NAME:
MI:
LAST NAME:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
NEW ADDRESS? YES NO
MAILING ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME PHONE:
CELL PHONE:
EMAIL ADDRESS:
SECTION 2: BENEFICIARY INFORMATION
PRIMARY BENEFICIARY
FIRST NAME:
MI:
LAST NAME:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
BENEFIT PERCENT:
MAILING ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME PHONE:
CELL PHONE:
E-MAIL ADDRESS:
RELATIONSHIP:
BENFICIARY #2 PRIMARY CONTINGENT
FIRST NAME:
MI:
LAST NAME:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
BENEFIT PERCENT:
MAILING ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME PHONE:
CELL PHONE:
E-MAIL ADDRESS:
RELATIONSHIP:
BENFICIARY #3 PRIMARY CONTINGENT
FIRST NAME:
MI:
LAST NAME:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
BENEFIT PERCENT:
MAILING ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME PHONE:
CELL PHONE:
E-MAIL ADDRESS:
RELATIONSHIP:
Designation of Beneficiary Other than Spouse or Domestic Partner
(To be completed if choosing 60% continuance option)
Page 14 of 34
RETIREE INFORMATION – PAGE 2
FIRST NAME:
MI:
LAST NAME:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
BENFICIARY #4 PRIMARY CONTINGENT
FIRST NAME:
MI:
LAST NAME:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
BENEFIT PERCENT:
MAILING ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME PHONE:
CELL PHONE:
E-MAIL ADDRESS:
RELATIONSHIP:
BENFICIARY #5 PRIMARY CONTINGENT
FIRST NAME:
MI:
LAST NAME:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
BENEFIT PERCENT:
MAILING ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME PHONE:
CELL PHONE:
E-MAIL ADDRESS:
RELATIONSHIP:
SECTION 3: REQUIRED SIGNATURES
I hereby nominate the above-named beneficiary to receive a return of any member contributions, still on deposit, in the
event of my death and the death of my spouse/domestic partner at the time of my death and upon receipt of a
photocopy of my final certified death certificate. I also acknowledge that any amounts owed to Stanislaus County
Employees’ Retirement Association upon my death, which are not recoverable will be deducted from this final benefit
payment.
This revokes any and all previous beneficiaries nominated for this benefit.
Date:
Printed Name:Applicant Signature:
Page 15 of 34
Type or print in ink.
SECTION 1: RETIREE INFORMATION
FIRST NAME:
MI:
LAST NAME:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
NEW ADDRESS? YES NO
MAILING ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME PHONE:
CELL PHONE:
EMAIL ADDRESS:
SECTION 2: BENEFICIARY INFORMATION
PRIMARY BENEFICIARY
FIRST NAME:
MI:
LAST NAME:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
BENEFIT PERCENT:
MAILING ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME PHONE:
CELL PHONE:
E-MAIL ADDRESS:
RELATIONSHIP:
BENFICIARY #2 PRIMARY CONTINGENT
FIRST NAME:
MI:
LAST NAME:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
BENEFIT PERCENT:
MAILING ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME PHONE:
CELL PHONE:
E-MAIL ADDRESS:
RELATIONSHIP:
BENFICIARY #3 PRIMARY CONTINGENT
FIRST NAME:
MI:
LAST NAME:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
BENEFIT PERCENT:
MAILING ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME PHONE:
CELL PHONE:
E-MAIL ADDRESS:
RELATIONSHIP:
Written Nomination of Beneficiary
$5,000 Retiree Death Benefit
Page 16 of 34
RETIREE INFORMATION – PAGE 2
FIRST NAME:
MI:
LAST NAME:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
BENFICIARY #4 PRIMARY CONTINGENT
FIRST NAME:
MI:
LAST NAME:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
BENEFIT PERCENT:
MAILING ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME PHONE:
CELL PHONE:
E-MAIL ADDRESS:
RELATIONSHIP:
BENFICIARY #5 PRIMARY CONTINGENT
FIRST NAME:
MI:
LAST NAME:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
BENEFIT PERCENT:
MAILING ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME PHONE:
CELL PHONE:
E-MAIL ADDRESS:
RELATIONSHIP:
SECTION 3: REQUIRED SIGNATURES
I hereby nominate the above-named beneficiary to receive a $5,000 death benefit at the time of my death and upon
receipt of a photocopy of my final certified death certificate.
This revokes any and all previous beneficiaries nominated for this benefit.
Date:
Printed Name:Applicant Signature:
Page 17 of 34
Type or print in ink.
SECTION 1: RETIREE INFORMATION
FIRST NAME:
MI:
LAST NAME:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
NEW ADDRESS? YES NO
MAILING ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME PHONE:
CELL PHONE:
EMAIL ADDRESS:
SECTION 2: BENEFICIARY INFORMATION
PRIMARY BENEFICIARY
FIRST NAME:
MI:
LAST NAME:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
BENEFIT PERCENT:
MAILING ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME PHONE:
CELL PHONE:
E-MAIL ADDRESS:
RELATIONSHIP:
BENFICIARY #2 PRIMARY CONTINGENT
FIRST NAME:
MI:
LAST NAME:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
BENEFIT PERCENT:
MAILING ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME PHONE:
CELL PHONE:
E-MAIL ADDRESS:
RELATIONSHIP:
BENFICIARY #3 PRIMARY CONTINGENT
FIRST NAME:
MI:
LAST NAME:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
BENEFIT PERCENT:
MAILING ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME PHONE:
CELL PHONE:
E-MAIL ADDRESS:
RELATIONSHIP:
Written Nomination of Beneficiary
Final Benefit Payment Upon Death
Page 18 of 34
RETIREE INFORMATION – PAGE 2
FIRST NAME:
MI:
LAST NAME:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
BENFICIARY #4 PRIMARY CONTINGENT
FIRST NAME:
MI:
LAST NAME:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
BENEFIT PERCENT:
MAILING ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME PHONE:
CELL PHONE:
E-MAIL ADDRESS:
RELATIONSHIP:
BENFICIARY #5 PRIMARY CONTINGENT
FIRST NAME:
MI:
LAST NAME:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
BENEFIT PERCENT:
MAILING ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME PHONE:
CELL PHONE:
E-MAIL ADDRESS:
RELATIONSHIP:
SECTION 3: REQUIRED SIGNATURES
I hereby nominate the above-named beneficiary to receive the final benefit payment payable to me, if any, at the time of
my death and upon receipt of a photocopy of my final certified death certificate. I also acknowledge that any
amounts owed to Stanislaus County Employees’ Retirement Association upon my death, which are not
recoverable will be deducted from this final benefit payment.
This revokes any and all previous beneficiaries nominated for this benefit.
Date:
Printed Name:Applicant Signature:
Page 19 of 34
Normal Retirement Age and Post Retirement Employment Questionnaire
General Members
I,
, hereby acknowledge that StanCERA staff has provided me with
Items “A” and “B” listed below and reviewed the requirements for being rehired after my retirement.
I understand that if I return to employment with a StanCERA covered employer, at a later date, the
same requirements and limits, stated below, remain in order as not to jeopardize my StanCERA
benefits.
A. PEPRA and I
RS Decision Tree for Rehiring Retired General Members
1.
Are you planning to return to work for a StanCERA Covered Employer?
If No, go to Item “B”
□
Yes
□
No
2. Are you age 62 or older?
□
Yes
□
No
3. Have you been offered a position to return to work by a hiring authority?
□
Yes
□
No
4. Is this appointment an emergency as defined by GC §7522.56?
□
Yes
□
No
5.
Has the emergency appointment been approved by the Board of
Supervisors?
□
Yes
□
No
B. Employmen
t After Retirement Pamphlet
• Required to s
it-out 180 days post-retirement prior to reemployment unless Board
of Supervisors approves exception due to critical staffing need in a non-consent
item (GC §7522.56);
• Retires unde
r the age of 62 required to sit-out 60 days post-retirement prior to
reemployment. This time runs concurrently with PEPRA requirements (IRS
requires Bona Fide separation from service);
• Post-retir
ement employment with a StanCERA employer limits you to work no
more than 960 hours or 120 days, which ever is greater, per calendar year (GC
§31680.3(a));
• Ineligible f
or employment if the retiree has accepted unemployment during the
last 12 months based upon post-retirement employment with any StanCERA
employer (GC §31680.3(b));
• Employmen
t with an employer who does not use StanCERA for retirement
benefit administration, whether public or private, will not affect your StanCERA
retirement benefits.
Member Signature: Printed Name: Date:
Page 20 of 34
Normal Retirement Age and Post Retirement Employment Questionnaire
Safety Members
I,
, hereby acknowledge that StanCERA staff has provided me with
Items “A” and “B” listed below and reviewed the requirements for being rehired after my retirement.
I understand that if I return to employment with a StanCERA covered employer, at a later date, the
same requirements and limits, stated below, remain in order as not to jeopardize my StanCERA
benefits.
A. PEPRA and IR
S Decision Tree for Rehiring Retired General Members
1.
Are you planning to return to work for a StanCERA Covered Employer?
If No, go to Item “B”
□
Yes
□
No
2. Are you age 50 or older?
□
Yes
□
No
3. Have you been offered a position to return to work by a hiring authority?
□
Yes
□
No
4. Is this appointment an emergency as defined by GC §7522.56?
□
Yes
□
No
5.
Has the emergency appointment been approved by the Board of
Supervisors?
□
Yes
□
No
B. Employment
After Retirement Pamphlet
• No sit-out peri
od for Safety Members, at age 50 or older, if returning to (GC
§7522.56);
• Public safety retirees under age 50 are required to sit out 60 days post-retirement
prior to reemployment (IRS requires Bona Fide separation from service);
• Post-retirement employment with a StanCERA employer limits you to work no
more than 960 hours or 120 days, which ever is greater, per calendar year (GC
§31680.3(a));
• Ineligible for employment if the retiree has accepted unemployment during the
last 12 months based upon post-retirement employment with any StanCERA
employer (GC §31680.3(b));
• Employment
with an employer who does not use StanCERA for retirement
benefit administration, whether public or private, will not affect your StanCERA
retirement benefits.
Member Signature: Printed Name: Date:
Page 21 of 34
Social Security Modification Option Acknowledgment Form
StanCERA members electing the Social Security Modification (Income Leveling) Option are required to
acknowledge the information in this document. Choosing the Social Security Modification is an
irrevocable decision made at the time of application of StanCERA Retirement Benefits.
If you qualify for Social Security Benefits, you may elect
to choose the Social Security Modification
(Income Leveling) Option and receive a monthly retirement allowance with an income leveling approach
rather than the fixed-for-life fashion of the original plan design. With this election, a member receives an
increased monthly allowance before age 62 from StanCERA, which is based on the Social Security
benefit estimate at age 62. The StanCERA benefit is reduced at age 62 at which time the member would
be responsible to apply for benefits directly with the Social Security Administration. It is recommended
that members apply for their Social Security benefits prior to their reduction of their StanCERA benefit.
StanCERA’s administration of the Social Security Modification (Income Leveling) Option is not subject to
any changes to the laws governing Social Security benefits. In the event Social Security modifies the
early retirement age from age 62, StanCERA will not modify the original payment agreement and would
still be required to reduce the StanCERA benefit at age 62.
This Option does not alter monthly continuance payments to the designated beneficiary. The
beneficiary’s continuance is based on the original payment option. The Social Security Modification
(Income Leveling) Option is not available to members who receive a disability retirement from StanCERA.
Understanding your Social Security Statement
Social Security Statements provide estimated benefit amounts using average earnings over a working
lifetime. Social Security assumes one will continue to work until age 62 (earliest eligible age to apply for
benefits), full retirement age (age 65 – 67 depending on birth year), or age 70. Social Security is unable
to provide an actual benefit amount until time of application.
StanCERA members who choose to retire prior to age 62 and elect the Social Security Modification
(Income Leveling) payment option, are required to submit an accurate Social Security estimate of eligible
benefits at 62 at time of application of StanCERA retirement. Members are encouraged to use the Social
Security Benefit Calculator, located on the Social Security Administration’s website, to obtain immediate
and personalized benefit estimate. This Benefit Calculator provides an optional stop-working age, which
would imply no future payments into the Social Security System from the time of retirement until age 62.
This option allows a more realistic estimate of the Social Security benefit. A link to this calculator may be
found by visiting StanCERA’s website at: www.stancera.org
.
If a member is eligible to receive a pension from employment in which Social Security taxes were not paid
and you also qualify for a Social Security retirement benefit, the Social Security benefit may be reduced
by the Windfall Elimination Provision (WEP). The amount of the reduction, if any, depends on the
earnings and number of years in jobs in which Social Security taxes were paid. To estimate WEP’s effect
on future Social Security benefits, information may be found on their website.
By signing below, you are declaring under penalty of perjury, that an accurate estimate of eligible Social
Security Benefits at age 62 has been provided, which is to be used for StanCERA’s Social Security
Modification (Income Leveling) Payment Option. It is understood that this option is irrevocable upon
activation of StanCERA Retirement Benefits.
Member Signature: Printed Name: Date:
Page 22 of 34
PAGE INTENTIONALLY LEFT BLANK
Page 23 of 34
RESCO
(RETIRED EMPLOYEES OF STANISLAUS COUNTY ORGANIZATION)
RESCO serves the retired employees of Stanislaus County and Special Districts. It is an independent
organization of retirees and is devoted entirely to the needs of the retirees. RESCO is the ONLY OFFICIAL
ORGANIZATION that represents all retired employees of Stanislaus County and its Special Districts. Anyone
who is presently receiving or anticipating a monthly retirement allowance from the Stanislaus County
Employees’ Retirement Association (StanCERA) is eligible to become a RESCO member.
RESCO
P.O. Box 1646
Modesto, CA 95353
(209) 521- 1666
www.RescoToday.org | Contact@RescoToday.org
My signature below is an acknowledgment that StanCERA has informed me that due to confidentiality laws,
StanCERA will not automatically transmit my contact information to RESCO, unless I authorize StanCERA to
release my printed information. By marking "Yes" below, I am authorizing StanCERA to release my
information to RESCO, otherwise, it will be my responsibility to contact RESCO directly if I am interested in its
services.
I hereby authorize StanCERA to provide my initial contact information to RESCO upon retirement.
Yes
No
MEMBER NAME:
MAILING ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME PHONE:
CELL PHONE:
EMAIL ADDRESS:
MEMBER SIGNATURE:
Date:
Page 24 of 34
PAGE INTENTIONALLY LEFT BLANK
Page 25 of 34
INFORMATION REGARDING MEDICAL, DENTAL & VISION COVERAGE
Last Employer:
City of Ceres
East Side Mosquito Abatement District
Hills Ferry Cemetery District
Keyes Community Services District
Salida Sanitary District
Stanislaus Council of Governments
Stanislaus County
Superior Court
Medical Coverage:
I am under 65 years old
Yes
No
My spouse is under 65 years old
Yes
No
If yes, Stanislaus County Risk Management may have medical plans available.
Would you like information regarding these medical plans?
Yes
No
Contact Information:
Stanislaus County Risk Management
1010 Tenth Street, Suite 5900
Modesto, CA 95354
(209) 525-5715 | earlyretirees@stancounty.com
I am over 65 years old
Yes
No
My spouse is over 65 years old
Yes
No
If yes, RESCO Insurance may have medical plans available.
Would you like information regarding these medical plans?
Yes
No
Contact Information:
RESCO Insurance administered by Pacific Group Agencies
25876 The Old Road #11
Santa Clarita, CA 91381
(800) 511-9065 | insurance@rescotoday.org
Dental and Vision Coverage:
Dental and vision coverage is available for all retirees through RESCO Insurance regardless of age.
Would you like information regarding dental and vision plans?
Yes
No
Contact Information:
RETIREE NAME:
DATE OF BIRTH:
DATE OF RETIREMENT:
DATE OF TERMINATION:
MAILING ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME PHONE:
CELL PHONE:
EMAIL ADDRESS:
MARITAL STATUS:
SPOUSES NAME:
DATE OF BIRTH:
Signing below is an acknowledgment that StanCERA has informed me, that due to contact changes and
confidentiality laws, StanCERA will not automatically transmit my contact information to Stanislaus County
Risk Management, RESCO Insurance, or both unless I authorize StanCERA to release my information by
marking “yes” and signing above.
Member Signature:
Printed Name:
Date:
Page 26 of 34
PAGE INTENTIONALLY LEFT BLANK
Page 27 of 34
Applicant
Information
Page 28 of 34
Taxation of Your Retirement Benefit
This document provides a general summary of how StanCERA withholds payments and reports
payments to the Internal Revenue Service (IRS) and the California Franchise Tax Board (FTB).
These are general provisions and may not apply to all benefits. Individuals should consult with
an independent tax professional to ensure proper tax filings and the correct payment of federal
and state taxes.
Retiree Payroll Federal and State Income Tax Withholding Information
All StanCERA retirees who receive a pension are required to select one of three tax withholding
options:
• federal and/or state income taxes withheld according to tax tables based on
marital status and number of allowances;
• specific dollar amount withheld for federal and/or state income taxes; or
• no federal and/or state income taxes withheld (exempt).
For those who elect to have income withheld based on tax tables, monies will not be withheld
unless the gross monthly retirement allowance exceeds the minimum amount listed on the tax
table for your filing status. If a filing status is not chosen, StanCERA will default both State and
Federal elections to Married/3 until a change request is received from retiree.
Penalties may be assessed by the IRS and/or the FTB if enough tax dollars are not withheld, or
the correct amount of tax is not paid. Contact an independent tax consultant for individualized
information.
California State Tax Information for Non-Residents
Those residing outside the State of California, will not have California state taxes withheld unless
a withholding is elected. StanCERA is required to report all benefits paid to the California
Franchise Tax Board regardless of residency.
1099-R Tax Statement
Annually StanCERA provides a 1099-R containing benefits paid in the prior calendar year. This
documentation provides information such as gross amount received, taxable amount received,
Federal income tax withheld, State tax withheld, etc.
Service-Connected Disability Retirement
Service-connected disability retirement benefits received from StanCERA, all or a portion of the
benefits, may be nontaxable. The Internal Revenue Code provides special tax treatment if a
retirement is due to a service-connected disability.
If a service-connected disability pension is no more than half the final average salary as
determined by StanCERA, the entire amount is generally tax free similar to worker’s
compensation. If a service-connected disability pension is more than half of the final average
salary, then generally the portion that equals half of the final average salary is tax free and the
remainder is taxable. Any Cost of Living Adjustment (COLA) associated with a service-connected
disability pension is taxable or untaxable accordingly.
Page 29 of 34
Calculation of the Taxable Amount of Your Benefit
In general, the total amount received as a retirement benefit from StanCERA, except as described
above as a service-connected disability benefit, is taxable. However, if contributions were made
from post-tax funds, then these amounts may be recovered tax free. The amount received
annually, from post-tax contributions, are reported on the 1099-R.
StanCERA staff does not provide tax advice nor will answer personal tax questions. Any
questions regarding Federal income taxes should be directed to the Internal Revenue Service,
questions regarding California State taxes should be directed to the Franchise Tax Board, or a
personal tax advisor.
Page 30 of 34
Employment After Retirement
On September 12, 2012, the Governor approved the Public Employees’ Pension Reform Act
(PEPRA). This legislation effects retired StanCERA members working part-time.
A retiree may work for a StanCERA employer as a temporary (part-time) employee, without
reinstatement, if requirements meet the criteria of PEPRA.
In general, retirees receiving a benefit from StanCERA and not already working part-time for a
StanCERA employer on or before December 31, 2012, will not be allowed to return to work for a
StanCERA employer after December 31, 2012; however, there are some exceptions to this rule:
• If 180 days have passed since the retirement effective date and the employer certifies to
StanCERA that the retiree’s skills are needed to perform work of a limited duration or to
prevent an emergency stoppage of public business; or
• If 180 days have not passed since the retirement effective date and the governing body
of the employer declares, in a public meeting, that the retiree’s skills are necessary to fill
a critically needed position; and
• The retiree must not have received unemployment insurance compensation within 12
months prior to the expected date of employment.
*Public safety members are exempt from the “less than 180-day rule”
If the above criteria is met, then a retiree may return to work, not exceeding 960 hours per
calendar year.
Items of Note:
o Retirees do not accrue service credit or acquire retirement rights for temporary (part-time)
employment.
o It is the responsibility of the retiree and the employer to ensure employment remains in
compliance, as not to jeopardize any StanCERA retirement benefits.
o Working for an employer whose retirement benefits are not administered by StanCERA,
whether public or private, will not have an affect on any StanCERA retirement benefits.
If any questions remain contact StanCERA staff at (209) 525-6393 or retirement@stancera.org.
Page 31 of 34
Retiree Cost of Living Adjustment (COLA)
The retiree cost-of-living adjustment (COLA) is based on the average annual change in the U.S.
Department of Labor, Bureau of Labor Statistics Consumer Price Index (CPI) for All Urban
Consumers for the San Francisco Bay Area. According to the County Employees Retirement
Law of 1937, the Retirement Board must determine the appropriate COLA for StanCERA
retirement benefits and implement that COLA effective April 1 each year.
The maximum COLA benefit that can be granted in any given year is a 3% increase or
decrease. Any excess will be tracked on a retirement year basis, creating a COLA bank. If the
change in the cost-of-living is less than the maximum adjustment, the COLA bank is then
utilized to increase the COLA granted up to the maximum of 3% in those years.
Should a negative COLA adjustment become necessary, the accumulated COLA benefit
amount would be reduced by the negative adjustment percentage. If the retiree has banked
COLA, the maximum percentage increase allowable would be applied to offset the negative
adjustment up to the 3% maximum allowable.
It is important to understand that a cost-of-living decrease cannot reduce a benefit allowance to
be less than the original amount granted at the time of retirement.
The COLA is reflected annually on the May retirement check (payment of April benefits).
Members who have a retirement date on or before March 31 are eligible for that year’s COLA.
Members who retire after March 31 will be eligible to receive a COLA in future years, if
applicable.
Tier 3 members are not eligible for cost of living adjustments.
Page 32 of 34
NO
PEPRA and IRS Decision Tree for Rehiring General Members
• A retiree may not return to work, under any circumstance, if he/she has received unemployment insurance in the last 12 months with any StanCERA
employer.
• An emergency is defined in Government Code §7522.56 as (1) an event that would stop public business or (2) the appointment necessary to fill a
critically needed position.
Is retiree age 62 or older?
Is this appointment an
emergency?
Retiree may return with
Governing Board approval
or if 180 days has passed
since retirement.
Retiree may accept
appointment 180 days
after retirement.
Is this appointment an
emergency?
Retiree may return with
Governing Board Approval
Prior to retirement, was
there a pre-determined
arrangement to return to
work?
Retiree may not return
until age 62.
Retiree may accept
appointment 180 days
after retirement.
Page 32 of 33
NO
PEPRA and IRS Decision Tree for Rehiring Safety Members
• A retiree may not return to work, under any circumstance, if he/she has received unemployment insurance in the last 12 months with any StanCERA
employer.
• An emergency is defined in Government Code §7522.56 as (1) an event that would stop public business or (2) the appointment necessary to fill a
critically needed position.
Is retiree age 50 or older?
Is retiree returning to a
Safety Position?
Retiree may return to
work immediately.
Is this appointment an
emergency?
Retiree may accept
appointment 180 days
after retirement.
Retiree may accept
appointment 180 days
after retirement.
Is this appointment an
emergency?
Retiree may return with
Governing Board
Approval
Prior to retirement, was
there a pre-determined
arrangement to return to
work?
Retiree may not return
until age 50.
Is retiree returning to a
Safety Position?
Retiree may accept
appointment 60 days
after retirement.
Retiree may accept
appointment 180 days
after retirement.
Page 32 of 32
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