Form Rm 0018 0909 – Fill Out and Use This PDF

RM-0018-0909	PO Box 295
	Trenton, NJ 08625-0295

PUBLIC EMPLOYEES' RETIREMENT SYSTEM AND TEACHERS' PENSION AND ANNUITY FUND

NEW JERSEY DIVISION OF PENSIONS AND BENEFITS

APPLICATION FOR RETIREMENT ALLOWANCE

PART ONE: MEMBER INFORMATION (Please print - black ink preferred - or type.)

3.SOCIAL SECURITY NO. ______________________________ 4. DATE OF BIRTH ________________________________

MonthDay Year

5.	NAME ______________________________________________________________________________________________
	Last	First	Middle
6.	ADDRESS __________________________________________________________________________________________
	Street	Apt. No.
	____________________________________________________________________________________________________
	City	State	Zip
7.	HOME PHONE (________)___________________________	8. WORK PHONE (________) _________________________

9.HOME E-MAIL ADDRESS________________________________________________________________________________

PART TWO: ACKNOWLEDGEMENT OF TERMS AND CONDITIONS OF RETIREMENT

You must agree to and sign these terms and conditions when applying for retirement. If you fail to sign this acknowledgement your Application for Retirement Allowance will not be processed.

•I understand that I must meet all of the eligibility requirements for retirement and cannot submit an application more than one year before my retirement date (if eligible for Deferred Retirement, I may file more than one year in advance upon termination of employment).

•I understand that my employer will be notified that I have filed an application for retirement.

•I understand that if I cancel or change my retirement date and submit a new application with a later retire- ment date, it is my responsibility to notify my employer to ensure that any active health benefits are not canceled and that my employment remains uninterrupted.

•I understand that changing or canceling my retirement date does not guarantee continued employment with my employer.

•I understand that the beneficiary designation I am indicating on this retirement application supersedes all prior designations, even if my retirement is not yet effective or if I cancel my retirement. The Division of Pensions and Benefits will honor this as my most recent beneficiary designation on file, unless another beneficiary designation is made after the retirement application.

•I understand that if I die prior to the retirement date indicated on this retirement application, any retirement benefits that may be payable to a beneficiary cannot be paid until the retirement date selected.

MEMBER’S SIGNATURE	DATE
__________________________________________________________	_______________________________ , 20 __________

I have read and agree to the “Terms and Conditions of Retirement” and attest that the information provided on this application is true and correct.

SIGN THIS PAGE AND CONTINUE TO PART THREE

RM-0018-0909

PART THREE: RETIREMENT INFORMATION

10.RETIREMENT DATE — To be effective the first day of _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

MonthYear

11.PURCHASE INFORMATION — Have you applied to purchase pension service credit within the past six months?

12. TYPE OF RETIREMENT

SERVICE RETIREMENT – You must be age 60 or older to qualify for a Service Retirement. No minimum amount of service credit is required.

EARLY RETIREMENT – You must be under age 60 and have a minimum of 25 years of service credit. If you are under 55 years of age, your benefit will be reduced (see Fact Sheet #4, Applying for Retirement).

VETERAN RETIREMENT – You must be a qualified military veteran and meet minimum age and service credit requirements. (see Fact Sheet #4, Applying for Retirement).

DEFERRED RETIREMENT – You must be under age 60 and have a minimum of 10 years of service credit upon termination of employment. A Deferred Retirement becomes effective at age 60 if you have filed an Application for Retirement Allowance prior to that date.

13.SALARY INFORMATION — Were your last three years of service also the years you earned the highest salaries?

______________________	______________________	______________________
Year 1	Year 2	Year 3

14.SPOUSE, CIVIL UNION PARTNER, OR DOMESTIC PARTNER’S NAME (If naming a partner, submit a photocopy of your Civil Union Certificate or Certificate of Domestic Partnership along with this application.)

NAME ________________________________________________________________________________________________

Last

First

Middle

15.SPOUSE, CIVIL UNION PARTNER, OR DOMESTIC PARTNER’S ADDRESS (If different from yours.)

ADDRESS ____________________________________________________________________________________________

StreetApt. No.

____________________________________________________________________________________________________

City

State

Zip

CONTINUE TO PART FOUR FOR PAYMENT OPTIONS

RM-0018-0909

MEMBER’S NAME _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ MEMBERSHIP NUMBER _ _ _ _ _ _ _ _ _ _ _ _ _ __ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _

PART FOUR: CHOOSE A RETIREMENT PAYMENT OPTION AND NAME A BENEFICIARY

USE THIS PAGE FOR THE MAXIMUM OPTION OR OPTION 1 ONLY — Additional payment options are listed on the following page.

Indicate whether your choice for a method of payment is the Maximum Option or Option 1. Maximum Option and Option 1 beneficiaries share the benefit equally. Refer to Fact Sheet #5, Pension Options (in this booklet) for an explana- tion of each option. You will receive a monthly retirement allowance for your lifetime, regardless of which option you choose. Choosing an option other than the Maximum will reduce your retirement allowance. You cannot change your payment option once your retirement becomes “due and payable” (see Your First Retirement Check on page 2).

MARK ONLY ONE BOX.

MAXIMUM OPTION — NO PENSION BENEFIT TO BENEFICIARY — Largest allowance paid to you with no

pension benefit paid to a beneficiary upon your death. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

(You must sign here)

OPTION 1 — REDUCING RETIREMENT RESERVE TO A BENEFICIARY — Your beneficiary receives the balance of a reserve set up to pay your retirement allowance if you die before the reserve is depleted. You can name more than one beneficiary and you can change your beneficiary(ies) at any time after retirement.

NAME A RETIREMENT OPTION BENEFICIARY (OR BENEFICIARIES) FOR THE MAXIMUM OPTION OR OPTION 1 PRIMARY BENEFICIARY(IES)

	BENEFICIARY NAME(S)	RELATIONSHIP	BIRTH DATE	SOCIAL SECURITY NUMBER
				(Optional)
1.	__________________________________________	____________________	__________________	____________________________
	ADDRESS _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
2.	__________________________________________	____________________	__________________	____________________________

ADDRESS _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

CONTINGENT BENEFICIARY(IES) — If no Primary Beneficiary is living at my death, payment is to be made to:

	BENEFICIARY NAME(S)	RELATIONSHIP	BIRTH DATE	SOCIAL SECURITY NUMBER
				(Optional)
1.	________________________________	________________	______________	______________________
	ADDRESS _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
2.	________________________________	________________	______________	______________________

ADDRESS _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

(Attach additional sheets for 3 or more beneficiaries. Additional sheets must be signed and dated.)

MEMBER’S SIGNATURE	DATE
__________________________________________________________	_______________________________ , 20 __________

I attest that the information provided on this application is true and correct.

SIGN THIS PAGE IF SELECTING THE MAXIMUM OPTION OR OPTION 1 AND THEN CONTINUE TO PART SIX

OTHERWISE, CONTINUE TO PART FIVE, ON THE NEXT PAGE FOR ADDITIONAL PAYMENT OPTIONS

RM-0018-0909

PART FIVE: OPTIONS THAT PROVIDE A MONTHLY PAYMENT TO A SURVIVING BENEFICIARY

If you did not select the Maximum Option or Option 1, indicate your choice on this page for method of payment. Refer to Fact Sheet #5, Pension Options (in this booklet) for an explanation of each option. You will receive a monthly retire- ment allowance for your lifetime, regardless of which option you choose. Choosing an option other than the Maximum will reduce your retirement allowance to provide a monthly benefit to a beneficiary upon your death. The higher your beneficiary's allowance, the more your allowance will be reduced. You cannot change your payment option once your retire- ment becomes “due and payable” (see Your First Retirement Check on page 2).

Under Options A, B, C, or D, you can name only one beneficiary and you cannot change your beneficiary after retirement. If your beneficiary dies before you, your retirement allowance will increase to the Maximum Option.

OPTION A — 100% TO BENEFICIARY - INCREASE TO MAXIMUM OPTION — Upon your death, your beneficiary receives a lifetime monthly retirement allowance equal to 100% of your monthly allowance.

OPTION B — 75% TO BENEFICIARY - INCREASE TO MAXIMUM OPTION — Upon your death, your beneficiary receives a lifetime monthly retirement allowance equal to 75% of your monthly allowance.

OPTION C — 50% TO BENEFICIARY - INCREASE TO MAXIMUM OPTION — Upon your death, your beneficiary receives a lifetime monthly retirement allowance equal to 50% of your monthly allowance.

OPTION D — 25% TO BENEFICIARY - INCREASE TO MAXIMUM OPTION — Upon your death, your beneficiary receives a lifetime monthly retirement allowance equal to 25% of your monthly allowance.

Under Options 2, 3, and 4, you cannot change your beneficiary after retirement. Options 2 and 3 pay you a larger monthly retirement allowance than the corresponding Options A and C. However, under Options 2 and 3, if your beneficiary dies before you, you continue to receive the reduced allowance provided by that option.

OPTION 2 — 100% TO BENEFICIARY - PERMANENT REDUCTION — You can name only one beneficiary. Upon your death, your beneficiary receives a lifetime monthly retirement allowance equal to 100% of your monthly allowance.

OPTION 3 — 50% TO BENEFICIARY - PERMANENT REDUCTION — You can name only one beneficiary. Upon your death, your beneficiary receives a lifetime monthly retirement allowance equal to 50% of your monthly allowance.

RETIREMENT OPTION BENEFICIARY — For Options A, B, C, D, 2, and 3 you may list only ONE beneficiary.

BENEFICIARY NAME	RELATIONSHIP	BIRTH DATE	SOCIAL SECURITY NUMBER
			(Optional)
______________________________________	_________________	____________	_________________________

ADDRESS __________________________________________________________________________________________

OPTION 4 — CHOICE OF AMOUNT TO BENEFICIARY - PERMANENT REDUCTION — You can name one beneficiary or multiple beneficiaries. Upon your death, your beneficiary(ies) receives the lifetime monthly retirement allowance indicated.

OPTION 4 BENEFICIARIES (Attach an additional sheet for 3 or more beneficiaries. Additional sheets must be signed and dated.)

BENEFICIARY NAME(S)	RELATIONSHIP	BIRTH DATE	SOCIAL SECURITY NUMBER
			(Optional)

1.______________________________________ _________________ ____________ _________________________

ADDRESS __________________________________________________________________________________________

ENTER AMOUNT $___________________ (Can be no more than the Option 2 allowance.)

2.______________________________________ _________________ ____________ _________________________

ADDRESS __________________________________________________________________________________________

ENTER AMOUNT $___________________ (Can be no more than the Option 2 allowance.)

MEMBER’S SIGNATURE	DATE
__________________________________________________________	_______________________________ , 20 ___________

I attest that the information provided on this application is true and correct.

SIGN THIS PAGE AND CONTINUE TO PART SIX ON THE NEXT PAGE