Form 13 23 PDF Details

Engaging with the intricacies of planning for retirement, particularly within the context of service or disability retirement under the Maryland State Retirement Agency, underscores the vital importance of adhering to specific procedures and deadlines to ensure a smooth transition from active employment to retirement. The Form 13-23, a crucial document in this process, outlines the necessity for applicants to understand and meet specific criteria, whether applying for service or disability retirement. This form acts as a comprehensive guide, detailing the mandatory steps to seek approval and secure retirement benefits effectively. Critical to this process are the stipulated timelines—the form must be filed within 120 days of notification of Board approval for disability retirement, emphasizing the importance of timely action. Additionally, it underscores the significance of understanding associated stipulations, such as a bona fide separation from service and the impact of reemployment on retirement benefits. Importantly, the form also elaborates on the options available to retirees concerning their retirement allowance and the designation of beneficiaries. This dual focus on meeting procedural requirements and making informed decisions about one’s retirement allowance and beneficiaries reflects the overarching goal of the Form 13-23: to ensure that employees of the Maryland State Retirement Agency are adequately prepared and knowledgeable about their retirement, thereby facilitating a smoother transition from active service to retirement.

QuestionAnswer
Form NameForm 13 23
Form Length9 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min 15 sec
Other names Retirement Checklist - Maryland State Retirement and ...

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MARYLAND STATE RETIREMENT AGENCY

120 EAST BALTIMORE STREET

BALTIMORE, MARYLAND 21202-6700

APPLICATION FOR SERVICE OR DISABILITY RETIREMENT

 

 

IMPORTANT: If you are applying for disability, this form must be completed

 

 

and filed within 120 days of notification of Board approval for disability

 

 

retirement. COMAR 22.06.01.03B states that the disability retirement

 

 

application is submitted on the date that it is received at the Retirement

 

 

Agency’s mailing address. A disability form is not considered submitted if it is

 

 

provided to an employer of the applicant. Contact the Agency to confirm

 

 

receipt. COMAR 17.04.03.16E also states, if a State employee is approved

 

 

for disability retirement by the Maryland State Retirement Agency, unless the

 

 

employee resigns or is removed earlier, the employee shall be considered

FOR RETIREMENT

 

resigned from State service as of the 120th day after the approval.

FORM 13-23 (REV. 10/21)

USE ONLY

INSTRUCTIONS FOR COMPLETION OF APPLICATION

IMPORTANT: Read the following instructions and information carefully before filling out this form.

1.In addition to this form, you should complete Forms 85 (Direct Deposit - Electronic Funds Transfer Sign-Up) and 766 (Federal and Maryland State Tax Withholding Request).

2.If you have chosen payment Option 2, 3, 5 or 6, you must verify your beneficiary's date of birth by attaching a copy of his or her birth certificate, valid driver’s license or other proof of birth. You can name only one beneficiary under these options. For information on other acceptable proofs of birth date, call a retirement benefits specialist at the number shown above.

3.If you are electing Option 2 or 5, you cannot designate a beneficiary who is more than 10 years younger unless the beneficiary is your spouse or disabled child. If you elect Option 2 or Option 5 and designate your disabled child, you must submit a completed Form 143 with this application.

4.If you wish to purchase previous service or apply for military service for which you are eligible, ask your Retirement Coordinator for the proper form(s) and submit it with this application. Additional credit cannot be claimed or purchased after your retirement.

5.If you are choosing the Basic Allowance, the Option 1 Allowance, or the Option 4 Allowance and you wish to name more than one beneficiary, you should not fill out the “Designation of Beneficiary” section on page 5. Instead, fill out and attach Designation of Beneficiary (Form 4).

6.If you are eligible to participate in the State Employees Health Insurance Program, only Option 2, 3, 5 or 6 continue health program coverage for your eligible surviving dependents after your death. Contact your employing agency for details.

7.You may change your retirement allowance selection only by filing a change with the Maryland State Retirement Agency before your first payment normally becomes due. In most cases, the first payment is due 30 days after the effective date of your retirement. For example, if your effective retirement date is July 1 and you elected Option 5, you have until July 30 to change your option selection with the State Retirement Agency. You may not change your option selection after monthly benefit payments have commenced.

8.If you die before the effective date of your retirement, your beneficiary cannot receive a retirement allowance even if you have completed this form. If you are still in active service at the time of your death, your beneficiary is only eligible for the active service death benefit.

9.You may change your beneficiary at any time. Depending on the option you have chosen, however, your retirement allowance may have to be recalculated to reflect the change. Your benefit amount could be reduced as a result of the change. For more information, call a retirement benefits specialist.

10.You must retire within 30 days of separating from employment with a participating employer to receive additional creditable service for your unused sick leave. Unused sick leave is sick leave that was available to an employee as sick leave during employment and was not used before retirement. Any converted leave that was not sick leave during employment may not be reported.

11.Generally speaking, a member may not receive more than one type of retirement benefit.

12.If you have voluntary contributions in your account and have elected to withdraw them in a lump sum, you must attach completed Form 742 (Application for Withdrawal of Voluntary Funds), Form 193 (Trustee-to-Trustee Distribution Form) if applicable and Form 746 (Acknowledgement of Receipt of Safe Harbor Notice and Affirmative Election) to this application. These forms may be obtained by calling a retirement benefits specialist at the number shown below.

NEED HELP: If you need help to complete this form, or need information on your retirement benefits or retirement process, call a retirement benefits specialist at 410-625-5555 or 1-800-492-5909.

1 OF 9

FORM 13-23 (REV. 10/21)

Reemployment After Retirement

VIDEO: For an overview of this information, go to sra.maryland.gov, select YouTube or Vimeo and watch “Reemployment After Retirement.”

FOR RETIREES OF THE TEACHERS’ RETIREMENT/PENSION, EMPLOYEES’ RETIREMENT/PENSION, CORRECTIONAL OFFICERS’ RETIREMENT, OR LOCAL FIRE & POLICE PENSION SYSTEMS

Keep a copy of this information on file as a handy reference. You should also keep your Notice of Retirement Allowance that the State Retirement Agency sends to you as a new retiree. The Notice of Retirement Allowance lists the amount of your monthly retirement allowance, your designated beneficiary(ies) and your earnings limitation. Refer to your Notice of Retirement Allowance to identify the type of retirement you are receiving (service, ordinary disability or accidental disability) and the amount of your earnings limit. Then, apply the reemployment rules printed below to determine if an earnings limit applies for you. Once retired, you cannot enroll in another Maryland State Retirement and Pension System (SRPS) plan or the Optional Retirement Program (ORP).

Under no circumstances should your decision to retire be conditioned upon an offer of reemployment, and in fact, no offers of reemployment should be discussed by you and your employer prior to your retirement. However, if after your retirement you consider reemployment with an employer that participates in the SRPS you need to be aware of two important issues: Internal Revenue Service (IRS) guidelines regarding reemployment and Maryland retirement law regarding reemployment.

INTERNAL REVENUE SERVICE GUIDELINES REGARDING REEMPLOYMENT

There can be significant consequences to you and the SRPS if you retire before the normal retirement age of your plan and/or before age 59 1/2, and are reemployed with the same employer without a bona fide separation of service. Please note that all units of Maryland state government, including the University System of Maryland, are considered one employer.

The IRS can impose a significant tax penalty on your income if you are under the age of 59 1/2, retire and begin receiving your monthly retirement benefits, and are reemployed by the same employer from whom you retired. In order to avoid this penalty there must be a bona fide separation from service between you and your former employer.

If you retire before your normal retirement age, there are also serious IRS consequences to the SRPS if a bona fide separation does not take place following retirement and prior to reemployment with the same employer.

While the IRS has not specifically defined what constitutes a bona fide separation from service, it is clear that the greater the difference between your last job before retirement and the job being performed upon your reemployment, and the longer the break between the date of your retirement and the date of your reemployment, the more likely it is that there has been a bona fide separation of service. If you are reemployed to perform the same job, even if there is a reduction in your work schedule, this would not likely qualify as a bona fide separation of service unless there is a lengthy break in employment. Even arrangements where you are rehired as an “independent contractor” may not meet the IRS’ standard.

MARYLAND RETIREMENT LAW REGARDING REEMPLOYMENT

Maryland law requires that there must be a minimum of 45 DAYS between your retirement date and the date you are rehired by any employer that is a participating employer in the SRPS. This rule applies even if you retired from an employer that withdrew from the SRPS. All units of Maryland State government, including the University System of Maryland, are considered to be one employer under these reemployment rules.

Additionally, employment after retirement, under certain conditions, may cause your retirement allowance to be reduced.

SERVICE RETIREMENT

(For disability retirement rules, see following page.)

Applicable to all systems: If you accept employment with a participating employer, that is an employer who offers State Retirement Benefits to their employees (a list of these employers can be found on page three), you must notify the Board of Trustees in writing of your intent to accept reemployment and the amount of your anticipated compensation. If you accept employment with the same employer from which you retired, you are subject to an earnings limit. All units of Maryland State government, including the University System of Maryland, are considered to be one employer under these reemployment rules. If you are subject to an earnings limit, your allowance will be reduced only if your reemployment earnings exceed the earnings limitation printed on your Notice of Retirement Allowance.

Reemployment earnings are the annual reemployment compensation reported to the IRS that you received during a calendar year. Your benefit is reduced one dollar for every dollar you earn in excess of your limit, up to a maximum of the full retirement allowance. If you retired as an elected or appointed official, contact the State Retirement Agency to learn how the reemployment provisions apply to you.

Applicable only to Employees’/Teachers’ Systems: Additionally, if you accept an early retirement and have been retired fewer than 12 months, you are subject to an earnings limit if you return to work for any participating employer during the first 12 months of retirement.

SERVICE RETIREMENT: EXCEPTIONS

Applicable to all systems: Earnings limits do not apply if your average final compensation used in your retirement calculation is less than $25,000 and you are reemployed on a permanent, temporary or contractual basis. Earnings limits do not apply if you have been retired more than five years. With the exception of a January 1st retirement date, the five year period begins on January 1st of the year following the year of retirement.

Applicable only to Teachers’ Systems: Earnings limits do not apply if you are a teacher who meets all of the following criteria:

Is or has been certified to teach in the state,

Has verification of satisfactory or better performance in last assignment prior to retirement,

Has been appointed in accordance with §4-103 of the Education Article, and

Retired with normal service retirement, or retired with an early service retirement and has been retired at least 12 months

AND

(continued on following page)

2 OF 9

FORM 13-23 (REV. 10/21)

SERVICE RETIREMENT EXCEPTIONS

(continued from previous page)

Is employed as a classroom teacher, substitute classroom teacher or teacher mentor for the Maryland School for the Deaf or in a public school that

Is not making adequate yearly progress or is a school in need of improvement as defined under the federal No Child Left Behind Act of 2001, or

Is receiving funds under Title 1 of the federal No Child Left Behind Act of 2001, or

Has more than 50% of the students attending that school who are eligible for free and reduced-price meals, or

Provides an alternative education program for adjudicated youths or students who have been expelled, suspended or identified for suspension or expulsion from public school

AND

Shall teach in an area of critical shortage, or a special education class for students with special needs, or a class for students with limited English proficiency, or

Is hired to teach any subject or class or provide education services under a special limited provision granted to the superintendent.

The superintendent may also grant a special limited exception to the earnings limit if the retiree is employed at any school to teach in an area of critical shortage, a special education class with special needs, a class for students with limited English proficiency, or provide education services.

Earnings limits do not apply if you are employed: 1) as a principal within 5 years of retirement or 2) as a principal not more than 10 years before retirement and were employed in a position supervising principals in the retiree’s last assignment prior to retirement AND you are rehired as a principal at a public school outlined above.

Note: Teachers and principals must receive satisfactory or better performance evaluations each year to continue with the earnings limitation exception.

If you retired directly from employment as a faculty member with a 10-month salary at the University System of Maryland, Morgan State University, St. Mary’s College or a Title 16 community college and are reemployed by the same employer, the following types of compensation will not be subject to an earnings limit: bonuses, overtime, summer school or adult education salaries, temporary payments for special research, honorariums or vehicle stipends.

Applicable to Employees’ Systems (rehired health care practitioners): Retirees of the Employees’ Retirement and Employees’ Pension Systems who are reemployed on a contractual basis as a health care practitioner by the Department of Health and Mental Hygiene in a state residential center, chronic disease center, a state facility or a local health department are exempt from the earnings limitation (applies only to normal service retirement or early service retirement once the retiree has been retired for 12 months.)

Applicable to Employees’ Systems (rehired as parole and probation employees): Retirees of the Employees’ Retirement and Employees’ Pension Systems who are reemployed on a contractual basis as parole and probation employees in positions with the Division of Parole and Probation in the Department of Public Safety and Correctional Services are exempt from an earnings limit for not more than 4 years.

Applicable to Correctional Officers’ Retirement System (rehired correctional officers): Retirees of the Correctional Officers’ Retirement System who are reemployed on a contractual basis as a correctional officer by the Division of Corrections, the Division of Pretrial Detention and Services or the Patuxent Institution in the Department of Public Safety and Correctional Services in an eligible correctional facility are exempt from the earnings limitation for a maximum of 4 years (does not apply to a disability retirement).

Applicable to Teachers’ Systems and Employees’ Systems: Retirees of the Teachers’ Retirement System, Employees’ Retirement System, Teachers’ Pension System, and Employees’ Pension System who are reemployed by the same employer from which they retired are not subject to a reemployment earnings limitation if the current employer is a unit of Maryland state government and compensation does not include any state funds.

DISABILITY RETIREMENT

Suspension of Disability Retirement: An Ordinary or Accidental Disability allowance shall be temporarily suspended during a period of reemployment if a retiree is reemployed by any participating employer at an annual compensation that is at least equal to the retiree’s average final compensation at retirement. If the disability retiree is eligible to receive a normal service retirement or began receiving a disability retirement allowance before July 1, 1998, no suspension of benefits is applied. There is no additional benefit accrued while reemployed by a participating employer.

If suspended, the retiree’s allowance is reinstated on the first day of the month following the month in which the retiree ceased employment with the participating employer. Also, the retiree’s allowance at time of reinstatement is adjusted to reflect the accumulated cost of living adjustments during the period of suspension.

Earnings limitation for Ordinary Disability Retirees Only: If you have not reached normal retirement age and you accept employment with a participating employer and your current earnings from the employment exceeds your earnings limitation, then your benefit is reduced. The reduction is $1.00 for every $2.00 over the limit, if you have been retired less than 10 years. If you have been retired 10 years or longer, the reduction will be $1.00 for every $5.00 over the limit. If your pension is temporarily suspended as provided above, this earnings limitation does not apply during the period of suspension.

There is no earnings limit for an Ordinary Disability Retiree who is reemployed with a non-participating employer. The earnings limit does not apply for Accidental Disability Retirees.

Note: An additional exception to the suspension of benefits and the earnings limitation applies to law enforcement officers formerly employed by an employer that participated in the Law Enforcement Officers’ Pension System. These former officers are exempt if reemployed by a participating employer in any position other than a probationary status law enforcement officer, a law enforcement officer or chief, as defined in §3-101 of the Public Safety Article.

If you have any questions, call a retirement benefits specialist at 410-625-5555 or toll free 1-800-492-5909 to understand how the reemployment provisions apply to you. We will make every effort to assist you in understanding your options, but it is your responsibility to advise us of your reemployment.

3 OF 9

FORM 13-23 (REV. 10/21)

PARTICIPATING EMPLOYERS *

Maryland State Retirement and Pension System

State of Maryland

University System of Maryland

Baltimore City and All County Boards of Education (Teachers’ System)

Community Colleges and All Public Libraries (Teachers’ System)

Participating Governmental Units in the Employees’ System as of July 1, 2021

Allegany College of Maryland

Federalsburg, Town of

Prince George’s County Board of

Allegany County Board of Education

Frederick County Board of Education

Education

Allegany County Commission

Frostburg, City of

Prince George’s County Crossing Guards

Allegany County Housing Authority

Fruitland, City of

Prince George’s County Government

Allegany County Library

Garrett County Board of Education

Prince George’s County Memorial Library

Allegany County Transit Authority

Garrett County Community Action

Princess Anne, Town of

Annapolis, City of

Committee

Queen Anne’s County Board of Education

Anne Arundel County Board of

Greenbelt, City of

Queen Anne’s County Commission

Education

Greensboro, Town of

Queenstown, Town of

Anne Arundel County Community

Hagerstown, City of

Ridgely, Town of

College

Hagerstown Community College

Rock Hall, Town of

Berlin, Town of

Hampstead, Town of

St. Mary’s County Board of Education

Berwyn Heights, Town of

Hancock, Town of

St. Mary’s County Commission

Bladensburg, Town of

Harford Community College

St. Mary’s County, Housing Authority

Bowie, City of – Police Dept. (LEOPS)

Harford County Board of Education

St. Mary’s County Metropolitan

Brentwood, Town of

Harford County Government

Commission

Brunswick, City of

Harford County Library

St. Michaels, Commissioners of

Calvert County Board of Education

Housing Authority of Cambridge

Salisbury, City of

Cambridge, City of

Howard Community College

Shore Up!

Caroline County Board of Education

Howard County Board of Education

Snow Hill, Town of

Caroline County Sheriff Deputies

Howard County Community Action

Somerset County Board of Education

Carroll County Board of Education

Committee

Somerset County Commission

Carroll County Public Library

Hurlock, Town of

Somerset County Economic Development

Carroll Soil Conservation District

Hyattsville, City of

Commission

Catoctin & Frederick Soil

Kent County Board of Education

Somerset County Sanitary District, Inc.

Conservation District

Kent County Commissioners

Southern Maryland Tri-County

Cecil County Board of Education

Kent Soil and Water Conservation District

Community Action Committee

Cecil County Government

Landover Hills, Town of

Sykesville, Town of

Cecil County Library

La Plata, Town of

Takoma Park, City of

Centreville, Town of

Lower Shore Private Industry Council

Talbot County Board of Education

Chesapeake Bay Commission

Manchester, Town of

Talbot County Council

Chestertown, Town of

Maryland Health & Higher Education

Taneytown, City of

Cheverly, Town of

Facilities Authority

Thurmont, Town of

College of Southern Maryland

Middletown, Town of

Tri-County Council of Western Maryland

College Park, City of

Montgomery College

Tri-County Council for the Lower

Crisfield, City of

Morningside, Town of

Eastern Shore

Crisfield Housing Authority

Mount Airy, Town of

University Park, Town of

Cumberland, City of

Mount Rainier, City of

Upper Marlboro, Town of

Cumberland, City of - Police Department

New Carrollton, City of

Walkersville, Town of

Denton, Town of

North Beach, Town of

Washington County Board of Education

District Heights, City of

Northeast Maryland Waste Disposal

Washington County Board of

Dorchester County Board of Education

Authority

License Commission

Dorchester County Commission

Oakland, Town of

Washington County Library

Dorchester County Roads Board

Oxford, Town of

Westminster, City of

Dorchester County Sanitary Commission

Pocomoke, City of

Worcester County Board of Education

Eastern Shore Regional Library

Preston, Town of

Worcester County Commission

Edmonston, Town of

Prince George’s Community College

Wor-Wic Community College

Emmitsburg, City of

 

 

*NOTE: The list of employers that participate in the Maryland State Retirement and Pension System (SRPS) is subject to change at any time. This list is updated annually. To determine whether a particular employer participates in SRPS, call a retirement benefits specialist at 410-625-5555 or toll-free at 1-800-492-5909.

4 OF 9

FORM 13-23 (REV. 10/21)

APPLICATION FOR SERVICE OR DISABILITY RETIREMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APPLYING FOR: Check only one box.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APPLICANT'S SOCIAL SECURITY NUMBER Gender

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Service Retirement

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ordinary Disability Retirement

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(M or F)

Accidental Disability Retirement

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APPLICANT’S NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Initial

Last

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HOME ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Number and Street

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home telephone

 

____ -

 

____ - ______

 

Yes

 

Home email address: ___________________________________________

I do wish to have my home address released to an

 

 

I request that my

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

approved public employees’ organization. If left

 

 

 

 

 

 

 

retirement allowance

 

 

 

 

 

 

¯

 

 

 

 

 

 

 

¯

 

 

 

 

 

 

 

 

 

 

 

 

 

 

unchecked, my address will not be released.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

□□Yes

 

be effective on

 

 

Month

 

 

 

Day

 

 

 

 

 

 

 

 

 

Year

Have you applied to purchase all additional credit

 

Are you a U.S. citizen?

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

for which you are eligible and intend to purchase?

 

 

 

No

 

I have Voluntary Monies: (see instructions on page one)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

I want my voluntary funds refunded in a one-time distribution.

Have you applied for credit for your active duty

 

 

 

 

 

 

 

 

 

 

OR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

military service?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

I want my voluntary funds to remain as a monthly additional annuity

DESIGNATION OF BENEFICIARY: If more than one beneficiary will be designated by members who select either the Basic Allowance, the Option 1 allowance, or the Option 4 allowance complete the “Designation of Beneficiary” Form 4 instead of the following section. Retirees electing Option 2 or 5 cannot designate a beneficiary who is more than 10 years younger unless the beneficiary is the retiree’s spouse or disabled child. Check here to indicate that Form 4 is attached.

BENEFICIARY'S SOCIAL SECURITY NUMBER

Gender

DATE OF BIRTH

 

 

 

¯

 

 

¯

 

 

 

 

RELATIONSHIP _____________________

 

 

 

 

 

 

¯

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BENEFICIARY’S NAME

 

 

 

 

 

(M or F)

 

Month

 

Day

¯

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First

 

 

 

Initial Last

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BENEFICIARY’S ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Number and Street

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State

 

 

 

ZIP Code

I hereby apply to retire from the Maryland State Retirement and Pension System (“SRPS”) and by signing below I confirm that:

1.REGARDING PAYMENT OF MY RETIREMENT BENEFIT, I authorize the Board of Trustees of the SRPS (“Board”) to pay to me and my properly designated beneficiary or beneficiaries, according to the retirement allowance option I have chosen and my Designation of Beneficiary in this application. I agree on behalf of myself and my heirs and assigns, that payment so made shall be a complete discharge of the claim and shall constitute a release of the Board and SRPS from any further obligation concerning the benefit. I hereby direct that if each of my designated beneficiaries dies before me, the amount payable shall become a part of and be paid to my estate, or to the beneficiary or beneficiaries I properly designate hereafter in accordance with the rules and regulations adopted by the Board.

2.REGARDING EACH OF MY BENEFICIARIES, I want the designation of beneficiary in this application to take effect (check only one box):

ImmediatelyOnly upon the effective date of my retirement

I understand that if I check neither box or both boxes, then the designation of beneficiary in this application will become effective immediately and will replace all prior designation of beneficiary forms.

3.REGARDING REEMPLOYMENT, I have read and understand the information about reemployment after retirement on pages two through four of this application. I agree to notify the Board of my anticipated earnings if I return to work. I understand that exceeding the legal limit on my post-retirement earnings could cause a temporary reduction or termination of my monthly retirement allowance. I understand that, to retire, I must be separated from any and all employment and reemployment, of any kind whatsoever, for at least 45 days after my retirement effective date, with any employer that participates in the SRPS. I also certify to the Board that at the date of my retirement, I will be in compliance with that requirement, and that I have had no discussions about reemployment with any employer that participates in the SRPS.

4.REGARDING DEDUCTIONS FROM MY ALLOWANCE, if I elect to have any premiums, dues, or other expenses deducted from my allowance, I hereby authorize the Maryland State Retirement Agency to exchange my Personal Information (including but not limited to my name, Social Security number and the amount of the deductions) with the third party or parties receiving those premiums, dues, or other expenses.

You must sign and date this form in the presence of a Notary Public. Your application will be rejected and your retirement delayed if the date of your signature does not match the date of your appearance before the Notary Public as provided in the box below.

Complete Signature

________________

Date Signed

_______

5 OF 9

FORM 13-23 (REV. 10/21)

RETIREMENT ALLOWANCE OPTIONS

YOU MAY CHOOSE ONLY ONE OF THE FOLLOWING OPTIONS. INDICATE YOUR SELECTION BY SIGNING IN THE APPROPRIATE BOX BELOW.

BASIC ALLOWANCE:

The Basic Allowance pays you the largest possible amount of money each month until your death. All monthly payments stop at your death, including beneficiary health coverage for state employees. After your death, your beneficiary or estate will receive one payment if your death occurs on the 16th of the month or later.

SIGNATURE

 

DATE

 

 

 

 

 

 

 

 

 

 

OPTION 1:

Provides a lower monthly benefit than the Basic Allowance, but guarantees monthly payments that equal the total of your retirement benefit’s Present Value. The Present Value of your benefit is figured at the time of your retirement. If you die before receiving monthly payments that add up to the Present Value, the remaining payments will be paid in a lump sum to your designated beneficiary or beneficiaries who remain alive. For state employees: Option 1 does not provide for continued beneficiary health coverage after your death.

SIGNATURE

 

DATE

OPTION 2:

Provides a lower monthly benefit than the Basic Allowance, but guarantees that after your death the same monthly benefit will continue to be paid to your surviving beneficiary for his or her lifetime. No further payments will be made after the deaths of you and your beneficiary. If you choose this option, you must send proof of your beneficiary’s date of birth with this application. Retirees electing Option 2 cannot designate a beneficiary who is more than 10 years younger unless the beneficiary is the retiree’s spouse or disabled child.

SIGNATURE

 

DATE

OPTION 3:

Provides a lower monthly benefit than the Basic Allowance, but guarantees that after your death one half of the monthly benefit paid to you will be paid to your surviving beneficiary for his or her lifetime. No further payments will be made after the deaths of you and your beneficiary. If you choose this option, you must send proof of your beneficiary’s date of birth with this application.

SIGNATURE

 

DATE

 

 

 

 

 

OPTION 4:

Provides a lower monthly benefit than the Basic Allowance, but Guarantees the return of your accumulated contributions and interest as established when you retire. If you die before you have recovered the full amount of your accumulated contributions and interest, the remainder will be paid in a lump sum to your designated beneficiary or beneficiaries who remain alive. For state employees: Option 4 does not provide for continued beneficiary health coverage after your death.

SIGNATURE

 

DATE

 

 

 

 

 

OPTION 5:

Provides a lower monthly benefit than the Basic Allowance, but guarantees that after your death the same monthly benefit paid to you will be paid to your surviving beneficiary for his or her lifetime. It also provides that your monthly benefit will “pop-up” to the Basic Allowance for your lifetime the month following the death of your beneficiary if your beneficiary dies before you. If your original beneficiary dies and you are collecting the Basic Allowance and decide to name a new beneficiary, your benefit will be recalculated under Option 5 based on the new beneficiary designation.

If you choose this option, you must send proof of your beneficiary’s date of birth with this application. Retirees electing Option 5 cannot designate a beneficiary who is more than 10 years younger unless the beneficiary is the retiree’s spouse or disabled child.

SIGNATURE

 

DATE

OPTION 6:

Provides a lower monthly benefit than the Basic Allowance, but guarantees that after your death one half of the monthly benefit paid to you will be paid to your surviving beneficiary for his or her lifetime. It also provides that your monthly benefit will “pop-up” to the Basic Allowance for your lifetime the month following the death of your beneficiary if your beneficiary dies before you. If your original beneficiary dies and you are collecting the Basic Allowance and decide to name a new beneficiary, your benefit will be recalculated under Option 6 based on the new beneficiary designation. If you choose this option, you must send proof of your beneficiary’s date of birth with this application.

SIGNATURE

 

DATE

6 OF 9

FORM 13-23 (REV. 10/21)

APPLICATION FOR SERVICE OR DISABILITY RETIREMENT

IMPORTANT: This page must be completed by your employer and returned with your application unless you have been separated from employment for at least 60 days. If you have been separated from employment for 60 days or more, your former employer does not need to complete this page.

Employer’s Certification of Separation from Employment, Wages, Contributions and Sick Leave

For:

Applicant’s Name

Applicant’s Social Security number:

 

 

 

 

 

¯

 

 

 

 

 

¯

 

 

 

 

 

 

 

 

 

 

 

 

 

A. The most recent payroll period reported was:

 

 

 

 

 

 

¯

 

 

 

¯

 

 

 

 

 

 

 

 

 

 

 

 

 

Month

 

 

 

Day

B.The projected payroll information to be reported prior to retirement is:

Job Classification

Year

Contribution $ _____________

Standard hours _________ Actual Hours Paid _________ Pay Period Ending ___________________

 

MO

DAY

YR

Contribution $_____________

Standard hours _________ Actual Hours Paid _________ Pay Period Ending ___________________

 

MO

DAY

YR

Contribution $_____________

Standard hours _________ Actual Hours Paid _________ Pay Period Ending ___________________

 

MO

DAY

YR

Final

 

 

 

Contribution $____________

Standard Hours _________ Actual Hours Paid _________ Pay Period Ending ___________________

 

MO

DAY

YR

No retirement contribution is due for a pay period ending on or after the retirement date.

C. The employee is separating from employment with the employer. The employee’s last day on payroll is:

__

.

Federal law prohibits the Maryland State Retirement and Pension System from paying benefits prior to "separation from employment." "Separation from employment" may only occur on resignation, retirement, discharge, or death, and not on transfer, promotion, or otherwise continuing employment with the same employer without interruption. State law requires that there be a minimum of 45 days from the date of retirement and the date the individual is reemployed, on a permanent, temporary, or contractual basis, by: (a) the State or any other participating employer, or (b) a withdrawn participating governmental unit (“PGU”), if the retiree was an employee of the withdrawn PGU while it was a participating employer.

D. Salary Change: Did the employee’s salary change since most.....................................................................recent payroll period reported or will

YES

NO

the employee’s salary change before the date of retirement?

 

If yes, the employee’s new annual salary is $

and is effective

 

 

 

 

 

 

MO

DAY

YR

E.Unused Sick Leave: Member must retire within 30 days of separating from employment to be eligible to receive additional creditable service for unused sick leave. The agency must be notified of all changes in unused sick leave. Unused sick leave must be reported at the time the member files for retirement and again 30 days after the effective date of retirement. Retirement Coordinator: Please retain a copy and submit recertified sick leave 30 days after retirement. Unused sick leave is sick leave that was available to an employee as sick leave during employment and was not used before retirement. Any converted leave that was not sick leave during employment may not be reported.

Initial

Total DAYS of unused sick leave (If none, enter word NONE)

 

as of

 

 

 

Reporting:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MO

DAY

YR

 

 

 

 

 

 

 

 

 

Recertified

Total DAYS of unused sick leave (If no change, enter no change)

 

 

as of

 

 

 

Sick

 

 

 

 

 

 

 

 

MO

DAY

YR

 

Leave:

Retirement Coordinator recertifying leave must initial here:

 

Date:__________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I certify that the above information regarding wages, contributions, separation from service, and sick leave is true and accurate to the best of my knowledge and that I am authorized to certify this information by the employer. I will report any changes to unused sick leave occurring between the date certified and the actual date of retirement.

_________________________________

_______________________________

_________________________________

Signature of Authorized Agent

Printed Name of Authorized Agent

Title of Authorized Agent

_________________________________

_______________________________

_________________________________

Date

Full Name of Employer

DIRECT Telephone Number

Submit form directly to: Maryland State Retirement and Pension System, 120 East Baltimore St., Baltimore, MD 21202-6700

7 OF 9

FORM 13-23 (REV. 10/21)

Important Points To Know...

when filing the

Application for Service or Disability Retirement (Form 13-23)

Please review the following information when planning and filing for retirement. For retirement counseling call: 410-625-5555 or 1-800-492-5909.

Apply to purchase any eligible service credit that is not in your account by completing the Request to Purchase Previous Service (Form 26) in the 12 months before you retire. You must submit your request to purchase service prior to retiring. A purchase of service increases the amount of service in your account towards becoming eligible to retire as well as the amount of your retirement benefit.

Claim your military service by completing the Claim of Retirement Credit for Military Service (Form 43) and submitting it to SRA before you retire. You must have at least 10 years of creditable state service in order to claim military service that occurred prior to your membership. Claiming military service increases the amount of service in your account towards becoming eligible to retire as well as the amount of your retirement benefit.

Submit a request for an estimate by filing the Application for an Estimate of Service Retirement Allowance (Form 9) within 12 months of retiring. See the Important Points to Know sheet that accompanies Form 9 for more information.

Determine when you want to retire. Go to your Retirement Coordinator, usually someone in your person- nel or payroll office, and ask for the retirement forms to retire. You should receive the following forms:

Application for Service or Disability Retirement Form (Form 13-23)

Direct Deposit Electronic Fund Transfer Sign-Up (Form 85)

Federal and State Tax Withholding Request (Form 766)

Retirement forms should be sent to the Retirement Agency four to eight weeks before you retire. Form 13- 23 can only be sent to the Agency from your employer so please allow sufficient time for your employer to process information on the back of the form and send it to the Agency.

Ask any questions you have on retirement issues or forms to SRA retirement benefits specialists. You can make an appointment to see a specialist or you can talk with a specialist by calling 410-625-5555 or toll- free 1-800-492-5909.

Read carefully the first page of Form 13-23. Be sure you understand all information on the front page before completing the form. If you need any help, contact a retirement benefits specialist at 410-625-5555 or toll free at 1-800-492-5909.

Any unused sick leave days that you have at retirement may be converted into months to add to your monthly benefit provided you retire within 30 days of separating from employment.

Continued on following page.

The Maryland State Retirement and Pension System 120 East Baltimore Street · Baltimore, MD 21202-6700

sra.maryland.gov

8 OF 9

FORM 13-23 (REV. 10/21)

Important Points to Know when filing the Application for Service or Disability Retirement (Form 13-23)

Continued from previous page.

For State employees and employees of the University System of Maryland: If you are eligible to partici- pate in the State Employees' Health Insurance Program, only selection of Option 2, 3, 5, or 6 will allow your eligible surviving dependents to continue health program coverage after your death. You must choose either Option 2, 3, 5, or 6 and name your spouse as beneficiary in order for the spouse to contin- ue health insurance after your death.

Choose a retirement date. If you choose the first of a month as your retirement date, you will receive your monthly retirement benefit at the end of that month. If you choose a date other than the first of the month, your first retirement benefit will be paid the end of the following month and it will be for one month's income only. You must be separated from employment on the date that you enter as your retirement date.

If you have voluntary money, decide how you want that money paid to you. To verify if you have any vol- untary money, refer to your most recent Personal Statement of Benefits or call a retirement benefits spe- cialist at 410-625-5555 or toll-free 1-800-492-5909.

Name your beneficiary (ies). If you have selected Option 2, 3, 5, or 6, you may only name one beneficiary. If you choose the Basic Allowance, Option 1 or Option 4, you may name multiple beneficiaries. If you are naming multiple beneficiaries, check the box on Form 13-23 that indicates you are submitting Form 4 with your beneficiary information. Do not enter one beneficiary on Form 13-23 and the rest on Form 4. Enter multiple beneficiaries on Form 4.

Choose your payment option. Be sure you understand each option before making your choice. Your esti- mate should be helpful in choosing the option best suited to you and to those who may rely upon you for continuing income after your death. Contact a retirement benefits specialist if you have questions regarding the payment options. You may not change your payment option once your first payment comes due.

Submit proof of birth of your beneficiary if you choose Option 2, 3, 5, or 6. You may submit a copy of an unexpired driver's license, MD identification card provided by the Motor Vehicle Administration, birth cer- tificate, passport, or military documentation, as examples.

If you have chosen Option 2 or Option 5 and your beneficiary is your disabled child, you must have a physician complete the Verification of Retiree’s Disabled Child for Selection of Option 2 / 5 Beneficiary (Form 143) and attach it to this application.

Nooffersofreemploymentshouldbemadeordiscussedbyyouandyourcurrentemployeruntilafter

youhaveretired.Maryland law requires you to wait at least 45 days from your date of retirement before being reemployed as a retiree by your same employer. In this instance, all state agencies including the University System of Maryland are considered the same employer. If you return to work for the same employer, you may be subject to an earnings limitation as well as IRS rules may apply. Refer to the information contained in this packet for an explanation of the reemployment rules. If you have any questions, contact a retirement benefits specialist at 410-625-5555 or toll-free at 1-800-492-5909.

Again, to receive credit for any unused sick leave days you have at retirement, you must retire within 30 days from when you separated from employment. Unused sick leave is sick leave that was available to an employee as sick leave during employment and was not used before retirement. Any converted leave that was not sick leave during employment may not be reported.

9 OF 9

FORM 13-23 (REV. 10/21)