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The Application for Voluntary Superannuation Retirement allows a (City of Somerville)

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BROWSE CITY OF SOMERVILLE (MA) FORMS

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Introduction
Application for Voluntary Superannuation Retirement
Pursuant to Massachusetts General Laws, Chapter 32, Sections 5, 10(1), 10(2) and 10(3)
Form Last Revised: February, 2020
PUBLIC EMPLOYEE RETIREMENT ADMINISTRATION COMMISSION
FIVE MIDDLESEX AVENUE, SUITE 304 | SOMERVILLE, MA 02145
The Application for Voluntary Superannuation Retirement allows a member to apply to receive a superannuation
retirement allowance. This retirement allowance is based upon your age, years of service, group classification,
and salary. Those who entered service prior to April 2, 2012 may also use this form to apply for a Termination
Retirement Allowance pursuant to Massachusetts General Laws, Chapter 32, Section 32, Section 10(2).
• This Voluntary Superannuation form must be filed with your retirement board.
• A copy of your birth certificate, military discharge papers, marriage certificate and all other relevant
documents must be filed with this application.
• A properly completed Choice of Option at Retirement form must accompany this application.
• If you are an active employee or on a leave of absence, you can apply for retirement with the board
no earlier than four months before your intended date of retirement.
Eligibility Criteria for a Superannuation Retirement:
Minimum Requirements for Superannuation Retirement
Members Prior to April 2, 2012
Age at Retirement Years of Creditable Service
Any age 20 years of more
55 or older 10 years or more (Groups 1 & 2)
55 or older Any amount of creditable service (Group 4 only), subject to certain minimums
Members On or After April 2, 2012
Age at Retirement Years of Creditable Service Group
60 10 years 1
55 10 years 2
50 10 years 4
55 Any amount, subject to certain minimums 4
Application for Voluntary Superannuation Retirement
Pursuant to Massachusetts General Laws, Chapter 32, Sections 5, 10(1), 10(2) and 10(3)
Form Last Revised: February, 2020 2
Applicant Information
To the Retirement Board:
I respectfully request retirement for superannuation with years and months of creditable service.
My requested retirement date is:
Agency or Department Retiring From* Title/Position
Contact Information After Retirement (Enter only if different from present address)
Street and Number
City/Town State Zip Code Phone #
* For those retiring from regional or county retirement systems, please identify the community.
Member's Present Contact Information:
***-**-___ ___ ___ ___
Member's Last Name Member's First Name Social Security # (last four)
Street Address:
City/Town: State: Zip Code:
Email:
Phone:
Marital Status: Single Married Widowed Divorced
If Divorced, do you have a Qualied Domestic Relations Order (QDRO) in place?
YES NO
Name of Retirement Board:
Address:
City/Town: Zip Code:
Telephone: Fax:
Retirement Board: Please enter your retirement board information here.
Somerville
323 Broadway
Somerville
02145
(617) 764-3811
(617) 591-3211
PUBLIC EMPLOYEE RETIREMENT ADMINISTRATION COMMISSION
Application for Voluntary Superannuation Retirement 3
Member Last Name:
First Name: SSN: ***-**-__ __ __ __
Service Prior to April 2, 2012:
I entered service prior to April 2, 2012, and the following applies to me:
I have service in more than one Group, and I choose to have my group classification prorated.
I am presently in Group 1.
I am presently in Group 2 and have performed services in Group 2 for a minimum of 12 months prior to retirement.
I am presently in Group 4 and have performed services in Group 4 for a minimum of 12 months prior to retirement.
Service On or After April 2, 2012:
I entered service on or after April 2, 2012, and I understand that if I have service in multiple groups,
my group classifciation time will be prorated. The following applies to me:
During my public employment, I have served in more than one group.
I am presently in Group 1, and have spent my entire public employment in Group 1.
I am presently in Group 2, and have spent my entire public employment in Group 2.
I am presently in Group 4, and have spent my entire public employment in Group 4.
Employment History
Please supply all periods of prior governmental service in the Commonwealth of Massachusetts.
I was also employed by other governmental units/political subdivisions in the Commonwealth of Massachusetts
as follows:
GOVERNMENTAL
UNIT DEPARTMENT POSITION
DATES EMPLOYED
From: To:
To Which Group Do I Belong?
Your retirement board classifies you in a Group on the basis of the positon you hold. If you are in doubt about which Group you
are in, please consult with your retirement board. The four Groups are as follows:
• Group 1: “Officials and general employees including clerical, administrative and technical workers, laborers, mechanics
and all others not otherwise classified.” (Most people are in Group 1.)
• Group 2: Among the members of Group 2 are “Public works building police; permanent watershed guards and permanent
park police; University of Massachusetts police;” and many other specific positions including but not limited to fire or police
signal operators, and ambulance attendants of a municipal department who are required to respond to fires.
(The type of employment classified in Group 2 tends to be somewhat more hazardous than employment in Group 1.)
• Group 3: This Group is entirely made up of members of the Massachusetts State Police.
• Group 4: Among the members of Group 4 are “members of police and fire department not classified in Group 1,” and
many other specific positions including but not limited to correction officers, parole officers or parole supervisors, and
certain enumerated employees of a municipal light plant. (Generally speaking, Group 4 encompasses the most
hazardous occupations.)
PUBLIC EMPLOYEE RETIREMENT ADMINISTRATION COMMISSION
Application for Voluntary Superannuation Retirement 4
Member Last Name:
First Name: SSN: ***-**-__ __ __ __
Other Information:
I sign this application under the penalties of perjury. I affirm that the information presented in this application is correct,
complete and accurately presented. I understand that giving false or incomplete information may subject me to the loss of
my benefits as well as civil and criminal penalties.
Applicant's Signature:
Print Name:
Signature:
Date:
To Be Completed By Witness (should be disinterested party):
Name (Print):
Street Address:
City/Town: State:
Zip Code:
Signature: Date:
• Are you presently receiving a retirement allowance from any retirement system of any governmental
units/political subdivisions within the Commonwealth of Massachusetts?
If YES, please specify systems, date of retirement and retirement type.
YES NO
• Are you a veteran?
If YES, please specify military branch and dates of active service.
YES NO
• Have you been officially investigated for or charged with misappropriation of funds from your
employer or convicted of any crime related to your office or position?
If YES, please provide documentation.
YES NO
• Have you engaged in the practice of shift substitution on or after October 26, 2011?
If you answered YES, your Employer is required to fill out the Employer’s Shift Substitution
Certification form and file it with your retirement board.
YES NO
Termination Retirement Allowance
Are you applying for a Termination Retirement Allowance pursuant to the provisions of
Massachusetts General Laws, Chapter 32, Section 10(2), which is only available for those
who became members prior to April 2, 2012?
If YES, please briefly summarize the facts in the box below.
YES NO
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Completed 5 August 2020

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