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The Choice of Option at Retirement Form allows (City of Somerville)

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BROWSE CITY OF SOMERVILLE (MA) FORMS

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Introduction
Choice of Option at Retirement
Pursuant to Massachusetts General Laws, Chapter 32, Sections 12(1) and 12(2)
Form Last Revised: February, 2020
PUBLIC EMPLOYEE RETIREMENT ADMINISTRATION COMMISSION
FIVE MIDDLESEX AVENUE, SUITE 304 | SOMERVILLE, MA 02145
The Choice of Option at Retirement Form allows a member who has applied for retirement to select whether to
receive their entire retirement allowance during their lifetime or to leave a lump sum or allowance for their
survivor(s).
Keep in mind:
• You may only select one Option.
• Please consult with your retirement board to be certain that you understand the effect of selecting an
Option. Your retirement board can provide you with a personalized estimate of each benefit.
• If you are married, the Spousal Acknowledgement on this form must be signed by your spouse.
• A disinterested witness should sign pages 6 and 7 of this form.
Choice of Option at Retirement
Pursuant to Massachusetts General Laws, Chapter 32, Sections 12(1) and 12(2)
Form Last Revised: July, 2019 2
Instructions
When you apply for retirement, you may select one of three retirement allowance payment Options
(A, B or C). For the Option selection to be valid, this completed form must be filed with your retirement
board:
• On or before the date the board receives your written application for retirement, or
• On or before the date your allowance becomes effective, or
• Not more than 15 days after the board receives a written application for your involuntary
retirement from your department head.
1. You may change your Option selection before your retirement becomes effective by filing
a new form.
2. You may not change your Option selection once your retirement becomes effective.
3. If no Option selection is made, your allowance will be paid under Option (B).
4. If you are married, the spousal acknowledgement at the end of this form must be signed
by your spouse.
Name of Retirement Board:
Address:
City/Town: Zip Code:
Telephone: Fax:
Retirement Board: Please enter your retirement board information here.
Member's Information:
***-**-___ ___ ___ ___
Member's Last Name Member's First Name Social Security # (last four)
Street Address:
City/Town: State: Zip Code:
Email:
Phone:
Somerville
323 Broadway
Somerville
02145
(617) 764-3811
(617) 591-3211
PUBLIC EMPLOYEE RETIREMENT ADMINISTRATION COMMISSION
Choice of Option at Retirement 3
Member Last Name:
First Name: SSN: ***-**-__ __ __ __
1. Explanation of Retirement Options
After reviewing ALL of the retirement options below, please select ONE option by checking the corresponding box
in Section 5 on page 6.
Option (A) No Payment to Beneficiary
This Option provides for a full retirement allowance payable in monthly installments during your lifetime. All
allowance payments will cease upon your death and no benefits will be provided for any survivors.
Do not complete sections 3 & 4.
Option (B) Lump Sum Payment to Beneficiary
The payments under this Option are smaller than under Option (A). The annuity portion of your allowance
is reduced to allow a lump sum benefit for your named beneficiary(ies). Upon your death, your named
beneficiary(ies), or if there is no beneficiary living, the person or persons appearing in the judgment of the
retirement board to be entitled thereto will be paid the unexpended balance of your annuity account. Please
note that the contributions comprising the annuity account will be depleted within approximately twelve to
fifteen years depending upon your age at retirement. The longer you live, the less will be paid to your
beneficiary(ies) upon your death. If your account has been fully depleted, nothing will be paid to your named
beneficiary(ies). You may designate and change at any time, one or more beneficiaries to receive in designated
proportions, the lump sum Option (B) benefit. This Option takes effect upon your retirement and supercedes
any prior beneficiary selections. Do not complete sections 2 & 4.
Option (C) Payment of Allowance to Beneficiary
Election of Option (C) provides for a monthly retirement allowance during your lifetime that is less than you
would receive under either Option (A) or Option (B). Upon your death your designated beneficiary will be paid
a monthly allowance for the remainder of his or her lifetime. That allowance will be equal to two-thirds of the
allowance that you were receiving at the time of your death. The monthly allowance you receive under Option
(C) is based upon life expectancy factors for you and your designated beneficiary. Only your spouse, former
spouse who has not remarried, mother, father, sister, brother or child may be designated as your Option (C)
beneficiary. The younger your beneficiary, the smaller your retirement allowance will be. If, after you retire,
your Option (C) beneficiary predeceases you, you will thereafter be paid the full retirement allowance you
would have received had you elected Option (A) at the time your retirement allowance became effective. This
conversion is commonly referred to as the Option (C) “pop-up”. Please note that after the Option (C) “pop-up”
takes place you may not name another Option (C) beneficiary or choose another Option.
Do not complete sections 2 & 3.
PUBLIC EMPLOYEE RETIREMENT ADMINISTRATION COMMISSION
Choice of Option at Retirement 4
Member Last Name:
First Name: SSN: ***-**-__ __ __ __
2. Option A Only
There is no beneficiary when Option A is selected. Of all three options, Option A provides the highest possible monthly allowance
to a retiree. It does not provide for any continuing survivor benefits. Upon the death of the member who has selected Option A:
• All payments will stop.
• No future monthly payments will be made to anyone.
• No pay out of the remaining balance in the annuity account (if any) will be made.
• A pro-rata share of any amounts due at the death of the member (which will vary depending upon the date of the
member’s death) shall be payable to a recipient designated by the member.
I, , understand that in picking Option A only the amount of retirement
allowance still owed to me at the time of my death will be payable to a recipient or recipients designated by me.
I hereby designate the following to receive the pro-rata share of my retirement allowance still due to me on the date of my death.
Pro-Rata Recipient or Recipients:
% of
Benefit**
Full Name: (First, MI, Last): SSN/EIN*:
Relationship to You: Phone: Date of Birth:
Address:
Full Name: (First, MI, Last): SSN/EIN*:
Relationship to You: Phone: Date of Birth:
Address:
Full Name: (First, MI, Last): SSN/EIN*:
Relationship to You: Phone: Date of Birth:
Address:
Full Name: (First, MI, Last): SSN/EIN*:
Relationship to You: Phone: Date of Birth:
Address:
Full Name: (First, MI, Last): SSN/EIN*:
Relationship to You: Phone: Date of Birth:
Address:
*Recipient's full Social Security Number (SSN) or Employer Identification Number (EIN), if an organization.
**Total must equal 100%; if no percentages are indicated, benefit will be allocated equally among recipients.
%
0
PUBLIC EMPLOYEE RETIREMENT ADMINISTRATION COMMISSION
Choice of Option at Retirement 5
Member Last Name:
First Name: SSN: ***-**-__ __ __ __
Beneficiary's Name:
**Relation to Member: Date of Birth:
Social Security #:
Member's Signature Date:
Member's Social
Security # (last four):
***-**-___ ___ ___ ___
**Please include birth certificate and marriage certificate, if applicable.
3. Option B Only — Beneficiaries
If you selected Option B, please fill in your beneficiary(ies) below:
4. Option C Only — Beneficiary
If you selected Option C, please fill in your beneficiary below. An Option C beneficiary may only be your spouse,
former spouse who has not remarried, mother, father, sister, brother, or child.
Beneficiary Information:
% of
Benefit**
Full Name: (First, MI, Last): SSN/EIN*:
Relationship to You: Phone: Date of Birth:
Address:
Full Name: (First, MI, Last): SSN/EIN*:
Relationship to You: Phone: Date of Birth:
Address:
Full Name: (First, MI, Last): SSN/EIN*:
Relationship to You: Phone: Date of Birth:
Address:
Full Name: (First, MI, Last): SSN/EIN*:
Relationship to You: Phone: Date of Birth:
Address:
Full Name: (First, MI, Last): SSN/EIN*:
Relationship to You: Phone: Date of Birth:
Address:
*Beneficiary's full Social Security Number (SSN) or Employer Identification Number (EIN), if an organization.
**Total must equal 100%; if no percentages are indicated, benefit will be allocated equally among lump-sum beneficaries.
%
0
PUBLIC EMPLOYEE RETIREMENT ADMINISTRATION COMMISSION
Choice of Option at Retirement 6
Member Last Name:
First Name: SSN: ***-**-__ __ __ __
6. Witness Signature
To Be Completed By Witness (should be disinterested party):
To the Retirement Board - I have read this form with the member whose selection of an Option is made on this
document and at his or her request have witnessed his or her signature thereto.
Witness' Name (Print):
Street Address:
City/Town:
State: Zip Code:
Witness' Signature:
Date:
5. Option Selection and Signature
Please check the Option you have selected and sign your name at the bottom.
Member's Signature: I have read and understand the provisions of Option
selected above.
Print Name:
Signature: Date:
Social Security # (last four):
***-**-___ ___ ___ ___
Option (A)
I choose to have my retirement allowance paid in accordance with the provisions of Massachusetts
General Laws, Chapter 32, Section 12(2)(a) which provides the largest possible payment to me under the
retirement law and that all payments thereunder cease at my death. No payment will be made to any
beneficiary upon my death. If married, spouse must acknowledge this selection in Section 6.
Option (B)
I choose to have my retirement allowance paid in accordance with the provisions of Massachusetts
General Laws, Chapter 32, Section 12(2)(b) which provides for a smaller retirement allowance for my life
but provides that my designated beneficiary(ies) will receive any amounts remaining in my annuity
account at my death. If married, spouse must acknowledge this selection in Section 6.
Option (C)
I choose to have my retirement allowance paid in accordance with the provisions of Massachusetts General
Laws, Chapter 32, Section 12(2)(c) which provides an allowance which will be smaller than those under
Option (A) or Option (B) but that upon my death two-thirds of this allowance will be paid to the named
beneficiary for said beneficiary’s life. If married, spouse must acknowledge this selection in Section 6.
PUBLIC EMPLOYEE RETIREMENT ADMINISTRATION COMMISSION
Choice of Option at Retirement 7
Member Last Name:
First Name: SSN: ***-**-__ __ __ __
7. Spousal Acknowledgement
Unless there is a Domestic Relations Order in effect, if a member is married, the election of an option shall not be
valid unless it is accompanied by the signature of the member’s spouse.
• The member’s spouse must indicate that he/she has reviewed the Option selected and understands it.
• It is up to the retirement board to explain the three options to the member and the spouse.
• If an option selection of a married member is not accompanied by a spouse’s signature, the retirement
board will take steps, outlined in the statute, to contact the member’s spouse directly.
IMPORTANT: If you are the spouse of a member, please be certain you have read and understand the foregoing
provision relating to your spouse’s Option selection. If you do not understand any part of the Option selected by
your spouse, please ask for an explanation from your spouse’s retirement board. Your signature is not consent or
approval, only an acknowledgement of the Option chosen by your spouse.
• Do not sign below unless you understand the Option selected by your spouse and the benefits to
which you may or may not be entitled to at his/her death.
I am
, the spouse of
.
I understand my spouse has selected Option
as the method by which his/her retirement allowance will
be paid. This option may not be changed after retirement.
Spouse's Signature
Spouse's Name (Print):
Spouse's Signature: Date:
To Be Completed By Witness (should be disinterested party):
Witness' Name (Print):
Street Address:
City/Town:
State: Zip Code:
Witness' Signature:
Date:
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Completed 5 August 2020

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