service retirement election application · pdf filec^ers pieasep^^eyonr lumeastttpinuton...

C^ERS

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Service Retirement Election Application(B88) CalPERS (225-7377) • TTTfc (977) 249-7442

PteasedonotinaflcriMhurymrapptottontDCelPBIStnaeihenflOdaystelWByainvgfementdate;

Information About You

ltaM(Rntlttmt.lU«ailnlUal.LntllMB« SedtiSMUityNuaMrefCiiPEllSIO

Mdtm

ISalt Bf Cwauy

I ( )llrsi DM (BBMiVym) HoBaPtau tfttfaMrsoM

Please enter the last day

you received compensatkm

from CalPERS-covmed

eoptoyment

Please de not abtoevfste

yoirempliver^nanie

erpeefbontitle.

TheTesiponry/lnmiity

benefR torwMeti you se

efifibte is based on your

WEBS memberrtlp data

Inforniation About Your ReUroment

Pjeaa tvler tti the dstalted Intfnictiora la ttds pubScadon.

I 0S/o^Z£n,UttOiyMFir?tt|imMrnfn4

lGU;no U)gLV*<wyACAp<iwCffiSttyv

Hattriaenl ElfteVii Oati (rnawrym)

I SjC^Co am#

Temporary Aninilty • If you select this benefit, you must atso m out Secdon 3d. Option i Balance of(MrHiutions and/brTemporaryAnnuib Balance beneflciary(le^

lb piodde fm an additional Temporary Annufty Alioimnce. you etoct to reduce your monthly allowancetorllfe. afio

If you first became a memtrer on January 1.2002, or later, you elect to receive Temporary Annuity urdllage In the amount of'

(ezoTOi Ooean

The amount of your Temporary Annuity cannot exceed the estimated amount of your Soebl Security benefitat tfra age designated In ttds election.

if you fbst became a member prior to January 1,2002, you elect to rec^ Temporary AnnuRy imtfl age

httMamftmrffrf» permotith.PMer«Wltt«t»loBS} CMvs

OoRotastSodalSeeuTttyi Other l^fOniia Public Retbement SystemsndBtaiyornBtoed Are ymr a member of a CaSfomiapubBcielirefflent system dher than CalPERS? DNo Q^provlde:

ntfaGmeot as a CaSftantia ^ ^

ptibUcigtbBiiBitqraffl. I

Are you currently worttng With the Other system? GTNo OYbs

lte8rH)AO«V«aOttarSrf1ta(nBm«n^

C£:Oltt^ C-WWZIK•ft a • 000

fit nsj/sau ^k ■ ®M303a -J

STATE'S

I s EXHIBIT

f6S«008>«(1Vi1}

i ^'-fC&07S^

Attachment F CalPERS Exhibit 9 of 8

Put |fnf (iBim BDd SocisISecurfty mimber or oratS ID

•tttotopotMorypago

Section 2. ccntir.ucij

Hoys your employar

cofflplatetussectloa

Donettfsttchfron

application.

IWscsrtifie&ifonia

ratrsqubedMyni

an or were separated

lromCafPERS*oov«isd

sfflployisnt lor om than

tour ntonOis before your

retteinsiit datft

VMrNiai Sedat Stntity leabir ar CtlFBIS ID

Information About Your Retirement, continued

Emptoyar Certlflcatlop

PISBse retar to lbs dstalted instnicto bi this pubQcatfon (or more Informatioa.

taptoyn'* UM Oir w ftirao (naTM/ymlI D^/o^/nOtZ^Dadoyn'ri^mwi 6^ »udds/nw)'

Balance of unused tick teavBhotss on employee's dale of separationKttn Sirs

Balance of educatlonalieave hours on employee's date of separation ♦ a « —Nnin Osft

By tigting tnlOM^ you haisliy cerUtK under ttB penalty Of peifuiy; Ore! tire alnve brfonnation li tma oonpM^ ml

correct to ttn tat of yourkiiMlsdgo: clianges to tMs btfonuBn must be suimitted en an Afflsnded employer

MfunciBon voniL

StaamdEtBdortr Mm RUM (Rftt Nmm. IliMi iewsl. LMt Naad

MsKtos Tias d End»fSr r^Qwimuumi or upvyti Osw (MUOUnyy)

Ssistt only oM payment

optlomOptloni.Optbm?,

OptlimZW, Option 3,

talon 3H tin Unmodiesd

Allowance Option, o'rnie el

the Option 4 types.

Ttae options apply

teOptknetBArtduai

LBedmeBsneficlaryonlyL

Select Your Rettiement Payment Option and Bbneficlary

By BDIng out tMi sectftn, you are eloetkig your Ratlrement Payment OpdOR and dasignatfng your tenafieiiry.

Once you select a payment tatoi, you canntt change to another option. Along vritb your taton seiectlon, you mustcompiete ti least one of the tfenefidajy detifftations to Sections 3a^ tl you choose the UnmodiBed Allowattce OpdoR,you do not nsed to specify 8 ttsnefitayL Plesss refer to the detaBsd tostrectkms In this pubficadon for more totcrmaiiotL

□ Optionl • To comptetsthb option choice, you must at»fiD out Section 3d, Btianre of OonMMtaBsRtitary.

G Option2'Tocofnpl8tettdsopBonch(ta.vounnjstal8ornioutSectton3a.MMAQiliftfiimfisn8fci!vx.

^0ptta 2W • To contato tlds takn choice, you must alM IBI oto Secta 3a. llriOMta Ltaim Sstedtay*□ Qption3*TbcomptatMsopttonchoice.younustalsofBloulSeGlIon3a.MM(ftBftMtitafisrMfci0X.

G Option 3W'To csnptathto option choice, you nta also fiO cut Sscdoo 3a. todMataUMtaflentitair.

G Unmodified Allowance Oplion-lfyouseiectthisoptionthereisnoretumofyQurmembercontreutionsand nomonta benefits p^rtide iQxn yew deaSi' except tos Survivor Continuance Benifil.B appBcaUe-Tltere b no benefitiarydesignation tor this opdon.

G Option 4,Individual Lifetime Ben6ficiary-tiyouseiictthi8opeon.youimi8iaisos8iectonoiihsfoBiMingDRSMQuai ursBOM oensnoBiy opooos oeRMr.

Q OptiOQ2W&Oplion1Comtdned-Tocompiet80tlsap8onchoice.vounnstsl»f9oulSec(ton3atoAttBiIMta Pertefctoryand Section 3d fiaianre of

G Option 3W&Option ICkimtêd-locompletsthisopttonchoice.ynumusttinfil!outSection3ato(fi>totafIMSm^neMarfvAêtiian'iABStaaaf^CoiMjiôntBenBGdaty.

G Specific DollarAmount to Beneflciaiy? • To complBte this option choice, you must also GB out

G Spacifie Percentage to Beneficiary % • lb compioto this option choice, you must tiso 10 outSection 38

D Reduced Allowance by* OR. %tfiiDugliÔCdiBi PVCMI OMtlMWhmi

Byouare fttarâbeneficlaryundg thisopSon.you must aia (a out Section 3a. totfrttafLgBftweBwsfietoy.

G Reduced Allowance upon death of retiree or beneficiary:' reduction amount

tt you are ttttninBabeneficiajy under tfe option, you must aboBl out Section 3a. toiftMtaftitans Bwefietty.

feiseso-3G»40t/in P>S>2dS


' r: LJPut your oams^ara Soda]Security number tfgSlPSIS ID I OcSt

«ttItttDpof«toyp88t *"""»«• Sodal Stearltr Mosbtr er cilKRS IP

Seclion 3, cor.tinucti Select Your Retirement Payment Option and Beneficiary, continued

TMsopSofrepi^to □ Optfon 4, Multiple Lifetime Beneffcfaries-1b com;dristUs(vilondtdce, you must atsoflD out Section 3bOption 4 MuDwLtiettnM

These options apply toOption 4, Court Oiteed

Comnmdly Pr^erty onht

□ Option 4, Cotfft Ordered Communrty Property-Byouseiedttto you (TtosiaisocompMB section dc.Cbiflf tlifeiatfCft Senelfciay and selecione of the loBowlito Coim Ordered Ctmmimlty PRiparty oittons.

□ Option 4/Unino(fitied-Tha8 is no addltlona) beneficiary daslonation for this option.

□ Optlon4/1«toconip)etsthlsoptionchoic8.yourriurieltofU)outS6Ction3d,aalMosrrfQ9nfr&iiO]rise«to4d»y.

O Option 4/ZW - To compiste Otis opSon, you must also fSl out Section 3a, bOrkksl BeneSday.

□ Option 4/3W-lb compteto this option, you must aInfiO oh Section 3a. MriabafLAbttnefidwfttoy.

DesiBRata ona beneficiaryand povida ail d thaiperson's tntomafionineludiRefulnan&

Option 2,2W, 3,3W or 4 Individual Lifetime BeneficiaryComplete this section cniyM you chose eWter Option 2.2W; 3,3W or Option 4 trwBvldualUletima Beneficiary or Option4/2W or 4/3W Court Ordered Community PnH»rty.

NtsM (Rrst ustfi. MUdJe talUil, Lm Mm«) Sodii Secwity Uunbcf« CUPStS to

MM iwves^fyyyl rwasgaitif^totte

Sucliuii 3b

If you wantyourbendleiariBsto

lacatve an equal shareolyoiirbensfis,rto

oat specify a ddlar orpercentage dbenefh.

Option 4 Multiple Lifetime BeneficiariesCompleto ttds section only if you aetoctod tlptton 4 Mutt^to Lifetime Beneflclajtea.

Mm UMH. UMSt UkL iMt Nutt)

stfttOitopBarMrnn)lOitoi DftaaCayfpges

Soari SKBihy rSMbir« CiPBtS 0

RtttOanN^teaa DoBu/totMt «r BMtm

Ham PM Mnt. MIMt MUal. Uii Nmtl

einiiOitatsia/Mrmi)iPitM Dttatkmam

SdcW SKunr KUBtor or Cirau 0

RttiifeoitfptoVn OeOvmrctnierBinelh

SUtt 79

Section 3 contlmtos on page 4

PB0«O-3»Spi/1l) aaaadda


Put your name and Social f\SecinflytniRterorCstPBISID I In

ettbe top of every pap SetW SMsrfty HoaAv Of CilPEIIS ID

Option 4 Multiple Lifetime Beneficiaries, continued

N«me (Rnt Nuw. MiMM tolOil. Uil Kim^

i iDllili Qfta^8iitt0ita<BunAMfnnf GiaStf

Seew SecBflly Nvnbn or CAPERS ID

DaltfeatUetsVbv (Miv/hrcM of eMft

SUto »

Court Ordered Optfon 4 Community Property Beneficiary

List only the Complete tMs section only H you selected (^Mbn 4 Oniit Ordered Coonmintty Property.

Coition 4 beneficiary

that Is fSQuired by your !!■■■>■ MUM>»i.tiii»i i—Nun (FM M«a« Socw SMtttlT

court onlec. IW«» laMai. L«st HaoD

\ IDM» Oftnalv•MbOataOun/Mym) Diteir

ITM^ « COPERS D

ReiiUooiuptoyvu

beneflctoti8Slnre.lfyou

eroameiSfrerent

06fwicttrt8S forms

(^fianl balance end theTiempcianf Annuity balance,

see Informatimin this

pubOcalfon on compietlnsthe Post RUbwient

Lump Sum Beneflelajy

cap stut ap covttrp

Optioni Balance of Contributions and/orTemporary Annuity Balance Beneflciarypes)Complete tlds section only if yen selectBd Option 1, Option 4-2IV/1 or 3W/1 condrined w the Tbmpoiafy Annuityallmivwce. You may cinnge Ods benefldaryfies) at any time. THs designation auttmadcalty revidcos when then atinnge bi yuff marital status, domestic partnership status, or when thoo b a birth or ad^n of a cfdid. Ptease referto ttie detdled inUiuctlnis in this puUtcaBon fm mare iidonnation.

Nan* (FM Num. Utfv IbBM. lot Nam)

ennOatttmmMWpyyp)lOtMi QSwattScaMr

SeeW Seoattp NBUMr u CUPins D

AtlMioniiiptoVW

Stale ZIP

Rial PM Naut. WMi MUal. IM ll»R« SmM SMgrlii Nancr er CUPERS »

etna out tnuaWppprt ctiteu RtUUWlUl to IM

Slltl ZIP

Hum ̂ Rut. Hieiii tnUiU, Uil Nun) Sedd Sesutty NuaMf« CMPERS10

BMi Dil* tfws/W/yyyy) Omdti RiliUsfiilt^taVn

SUtl ZIP

P55«S0-96e-50tni)


\

' Put your mmeood SocielSecoBy number ofOalPBiS 10 1 'T>M I y

etthetDpo^werypega YbarHans Sedai Sacnltr Hnntar v CaiPBtt ID

'Section 4

AUApp^nbnusteomplet»|Mseetl9ii.

o

OesfsnateyCTftteneficlayy

to receiw you^^inq)'SumfMfredOBathBenu.

Retired Death Benefit

Thte sedim dflsignatss tto peison who win recelw your LumihSum RtiM Oeati) Bom Ybu may change Ms

h8n8fldary(l8^ tt any tlrtt& lite 4tes!BR8tion UihmaticaDy revokes when there b a change in your tnarttBl status,

domestle pam»nh^ status, or when Ihare is 8 Ur0) or adoptfam of 8 cMU. Please idar to the tetated Inshudbits

In tfte ladiBcaiton fer more btformalton.

^ Uuftl MfMM UlW. Uti Naa^

lOiMBfOiOatlimmMdym) fimSw

-

Adtfftu

Oti ' "

SocUl Seccrinr MunMr or CiiPCes 10

IMmbiubiphb Tbo

Sao v

Mam (Rnt Ntmt. MMia iiUal last Nam)

I IDumemn Data (oaM/ymi) Cinjir

iDuea □ftaalaataSar

Sesiil eaasttty NtnnOef or CatPEte ID

RaMlauMpioWu

SUla ZIP

Nina (RntKama, UUfla taWal. lastNaflw)

J IDtMa OFmHBBirth OatatmB/Wvm) Gastfar

Sodal Sacaey Nuabar Of CalPEllS to

RHaUenbiplsVM

Stata ap

Survivor Continuance

Rease refer to the detBOedlnstruGtions in ttte puUicatbn for more biformatfam.1. WHIyoubemtfrfedonyourreiirementdate? ONo Edves,piwUe:

Haow et^ona Rant. Wdtfia teisa), Usi Hama)

^ . iDuaia BfaameiitbDaiilRaemwnn) fiandr

<1

SmW Saoiriqr Kanbtt v OidRRS 0

DatooiManl^'

1 04- I 1Stata ZIP Cevatry

Section 5 continues (n page 6

pets-BSD-ssMai/ti) feoaSofB


8t the top of every psgs SMIoI SMSftly MnMt M waM Mt« H#

Section 5, ccntirued Survivor Continuance, continued ' *

2. WiD you be registered with OToCanfomiaSeaetary of State as being b a (hnnestic partnership onyour retirement date? I^No OVbs. provide:

NMft «l OOBMUt ftftBW (FM Nmm. MUdto WUal. Uit Nwft

I tniMB Dfta^tiitaomramrMwrr) enwr

Sotui SacBftiy Numbtr or dlPBIS 10

DaUolRfttlilvM PBftmnUolmm/M/nyy)

SM« VP

3. DDyoulaveanyrBturala'adoptedunmarnedchHdrenunderagelB? QVeSiprovide;

Hmm •( cue mm IbM. ttlMM MW. IM Nant) SecM SMWtiy NbaMt a CMKBS n

ttthntstacMd/nmniPMib PftBate6Md«

NmmbI CUU (Rnt aaao. watt utw.uti ittme) Social SMottr Ibattr or CtfCKS 10

StiOtnia{BmMdmfnrt

IPMHi Ptettfienair

SttU) UP

4. Doyouhaveamunmanriedcliiidrenwtiowefer&sabiedpiiortothelriethbifthdayandwboarestlDdisabietf? QVbs. provide:

Ntm 0l CbBd {HrM Itoo. MWtt Ulisi. lait N8»«

I IDiaatt PtoaaBirth Paio(flawmmtl Ccstt

SodU SotwIiB MoaOor or Cams 0

Naiw e( Qtaa (Rm Naat. MMtt Initial, tjtf Naa^

Btneatt{o»M«wn)

tPiiaii PfaattUWWi

Sedar Sacartv Nottar er MTESS10

Staia m

Secdoa 5 cofltinties en page 7

PERS«0-3i»-S01/ll)


Tiityouritsms^Soctal ^SocBrtty number or CslPERSn) [

0tlh8topo!§BfVP8B9

Section 5, co:Uir.L;:;d Survivor Continuance, continued

5. Are your |»rents dependent upon you for one^ Of their support? 0^ □Ute.pfmfde:

Ntttt of Percflt (flnt NiM. IMtfit talOal. Usi Naae)

Urtn Dttt (Dn/dd/imnf)IDhui QftBan

SecU S«eurtiy ihnatar er CUPOISID

ttBse Pmi (Rni Hen*. HMe IbMbL Usl NaiM) Sedai Seeeuiy Naneer er CbTOS n

Urn Den (nnMe/nn) 6mm

Tax Witiiholdlng ElectionPlease choon mi only. FBiler8ltncom8Taili>fonnaStin.Pleassreferb)lliedetBnedtn$tnietkms]nih)ipub1eationteinorebift»nn6ihn.

per month.□ Withhold federal Income tax in the amount of!Odlirs

□ WIlhhcMfederailncome tax tresed on the stables (on

□ Am«rfedlndivldua] tax wlthholflng exaiiptlum.Uvatm

□ A ̂ ngle IniSvidua) wtth tax withholding exemptions.Hufflber

In addition to the amount withheld based on the tax tables, withhold L

Please choose one enht state loccae lax tftfonnatlon. Please refg to the detailed testntcCons in tMspuMeaBonferreoretatDnnflllon.

Slate wfthltthllng I not withhofd State Of Calitixi^ income tax.

isepifa^for □ wthhoW State of Callfomta Income tax In the amount of Lout«o(^tste midents.

.pa'month.

□ Withhold State of Callfomla income tax based on the tax tables ftv:

□ A married IndlvfdtialwHh tax wlthhotdlng exemptions.itMHOor

□ A tingle IniSvidual wHh tax withholding exemptions.MuBMr

In addition to the amount wthhtid based on the tax tables, withhold' .per month.

□ Withhold State of Callfbnda income tax In the amoiHitof 10 percentof the federal bicome taxwIthlxM'mg amount

psis4so-3a*s(ivii)


/-s

tlfltstopsltvMypmv ^Bitosw SeeM SMnlly Imbtr er cum n

Seciioi) 7

iMsttcBonfmsi lcertl^,unitettttp8naftydpcd«y»thatftelinfannatioo8ubntiltedhOTonbtnttandcoffecttoth>li8Stdinytuoooiplstedor

your appflnffin will

banturMd.

ttyoiffapaiBaDior

donWBopoitnflrt

tf Iffltuninflllflli

SMUnstrucfiooototMs

piAllcsBoii 00 ooRiploSi^y

tho JUtfScOlloo (ox

Absoneo of apniiiimlbnn.

Kbor tfonsboB and your

spousoôrdBnarile

partooi^ ̂ôobno musfbo ootBtaod by i notary

or wtttNsiod ̂ a

CayERSiopie«iilalh>&

□No

biPBrtnofsblp □Divoroed/iftnauBed

btMBW fjiboiOpdmfliw

StateofOBlIfoniia»Counôf

On boforomo.Otts Hsns w wwfFwnBiQ

ttio ioflAuinont On persont^ or fta entfly upon bahatf of adilch d» peisontol acted, exoouted Iho bBtnananLI ooffi^ under ftnally of onOtf Oto laws of On Slate of CatSonda Ont On (diegotog paiafiiapb is trueendconecL

Notary Seal

Illative aignanife. .

Ifsx. ,S/?J-/A>.OitiOBaMflkm}

CalPERS Benefit Services PMelon»RO. Box 9427tl, Sacramento, Cailfomia 94229-2711

pEi»eso48es(iins) nosotra


service retirement election application · pdf filec^ers pieasep^^eyonr lumeastttpinuton...

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