Calpers Retirement Application Form – Fill Out and Use This PDF

Provide your name as it appears on your Social Security card.

Enter Your Name (First Name, Middle Initial, Last Name) and your Social Security Number or CalPERS ID.

Enter your Address, City, State, ZIP, Country and Email Address.

Enter your Birth Date (mm/dd/yyyy), Daytime Phone and Alternate Phone.

Enter the last day you were on payroll with a CalPERS-covered employer as Last Day on Payroll (mm/dd/yyyy), and enter Your Retirement Date (mm/dd/yyyy).

Do not mail or deliver your application to CalPERS more than 120 days before your retirement date.

Enter the Employer Full Name and the Full Position Title.

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: I became a member prior to January 1, 2002, or I became a member on or after January 1, 2002, and have CalPERS service coordinated with Social Security.

If you are a member of a defined benefit plan with a California public retirement system other than CalPERS, enter the Name of Reciprocal System, the Last Day of Employment With Reciprocal System (mm/dd/yyyy) and the Retirement Date With Reciprocal System (mm/dd/yyyy).

Choose one of the retirement payment options.

Unmodified Allowance: There is no beneficiary designation with this option. Skip to Section 5.

Return of Remaining Contributions Option 1: Complete your beneficiary designation in Section 4c.

100 Percent Beneficiary Option 2: Complete your beneficiary designation in Sections 4a and 4c.

100 Percent Beneficiary Option 2 with Benefit Allowance Increase: Complete your beneficiary designation in Section 4a.

50 Percent Beneficiary Option 3: Complete your beneficiary designation in Sections 4a and 4c.

50 Percent Beneficiary Option 3 with Benefit Allowance Increase: Complete your beneficiary designation in Section 4a.

Flexible Beneficiary Option 4: Choose Specific Percentage or 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.

Name one or more beneficiaries to receive the Retired Death Benefit upon your death.

You can change this beneficiary designation at any time.

If you last worked with another California retirement system that provides a similar death benefit, the CalPERS Retired Death Benefit is not paid.

1. Were you married or in a registered domestic partnership at least one year prior to your retirement date? Mark No or Yes, provide: the Name of Spouse/Registered Domestic Partner.

2. Do you have any natural or legally adopted unmarried children under age 18? Mark No or Yes, provide: the child.

3. Do you have any unmarried children who were disabled prior to their 18th birthday and who are still disabled? Mark No or Yes, provide: the child.

4. Are your parents dependent upon you for one-half of their support? Mark No or Yes, provide: the parent.

In Step 1: Federal Tax Withholding Election, choose only one. If you choose Do not withhold federal income tax, skip to California State Tax Withholding Election at the end of this section.

Withhold federal income tax based on the tax tables for: Single or Married - Filing Separately, Married - Filing Jointly or Qualifying Widow(er), or Head of Household.

Complete Steps 2-4 ONLY if they apply to you; otherwise, skip to California State Tax Withholding.

In California State Tax Withholding Election, choose only one. You can mark the box Do not withhold State of California income tax. State withholding is optional for out-of-state residents.

Withhold State of California income tax based on the tax tables for: Single or Married (with two or more incomes), Married (one income) or Head of Household, with the Number of allowances.

Mark Checking, Savings, Joint or Trust Account, and enter the Routing Number (nine digits) and Account Number.

CalPERS does not accept a prepaid debit card as a payment option.

If you are authorizing your payment to your savings account or do not have pre-printed, personalized checks, have your financial institution complete the information.

Use tape to attach your voided, pre-printed personalized check. Do not staple or paper clip. No deposit slips.

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: I decline continuation of my CalPERS health coverage into retirement.

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.

Your signature must be notarized by a notary public or witnessed by a CalPERS representative.

This section must be completed or your application will be returned.

You certify, under the penalty of perjury, that the information submitted hereon is true and correct to the best of your knowledge.

Are you legally married or do you have a state-recognized registered domestic partner? Mark Yes or No. If no, indicate Never Married or in Domestic Partnership, Divorced, Annulled, or Domestic Partnership Terminated, or Widowed.

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.

You only have 30 days from the issuance of your first retirement benefit check to cancel or make any changes to this application.

Mail to: CalPERS Retirement Benefit Services Division, P.O. Box 942711, Sacramento, California 94229-2711.