Form 13 23 – Fill Out and Use This PDF

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.

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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)

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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.

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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.

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):

 Immediately Only 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

_______

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FORM 13-23 (REV. 10/21)