459-364 SRAindd

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					        Preretirement Guide

                                      PO Box 23700, Tigard, OR 97281-3700
                                      Phone: 503-598-7377 toll free 888-320-7377
                                      Fax: 503-598-0561 website: http://oregon.gov/pers                               2163
                                                                                                                      Social Security number*
Tier One/Tier Two Service Retirement Application
                                                                                                                      PERS number (optional)
Section A: Applicant information (required)
                                                                                                                                 Male  Female 
First name                       Middle initial                    Last name                          Date of birth                        Gender


Mailing address (street or PO box number)                                 City          State           Zip+4 code                       Phone

Are you a U.S. citizen or resident alien? Yes                               No  If no, complete a W-8BEN.

My retirement date is the first day of                                                                     ,                          .
                                                                             Month                                 Year

Section B: Retirement options (required) (Choose only one of the 13 options.)
 Option 1                                                        Lump-Sum Option 1**                                  Total Lump-Sum Option**
 Option 2                      Option 2A                        Lump-Sum Settlement                                  Lump-Sum Settlement
                                                                    Option 2**                                            Option 2A**
 Option 3                      Option 3A                        Lump-Sum Settlement                                  Lump-Sum Settlement
                                                                    Option 3**                                            Option 3A**
 Refund Annuity  15-Year Certain
**If you have chosen a lump-sum option, you must also complete Sections E and F.
Section C: Beneficiary election (required)
Fill out either Part 1 (below) or Part 2 (page 2).
The option you chose in Section B determines which section you should fill out.
• Fill out Part 1 if you chose Option 2, 2A, 3, 3A, Lump-Sum Option 2, 2A, 3, or 3A.
• Fill out Part 2 (page 2) if you chose Option 1, Refund Annuity, 15-Year Certain, Lump-Sum Option 1, or
  the Total Lump-Sum Option.
Part 1: Beneficiary for (Survivorship) Option 2, 2A, 3, 3A, Lump-Sum Option 2, 2A, 3, or 3A
• You can only name one beneficiary.

• You must include proof of beneficiary’s date of birth when you submit your retirement application.
You can change the beneficiary you name below only within the first 60 days after the issue date of your
first benefit payment. This beneficiary designation becomes irrevocable after that time.

Beneficiary’s full name                                                                Beneficiary’s Social Security number



Beneficiary’s date of birth                                                           Beneficiary’s relationship to you (e.g., wife, brother, etc.)


*Providing your Social Security number (SSN) is mandatory, and PERS is authorized to request it under provisions of the Internal Revenue code. It will primarily be used
 to comply with mandatory IRS reporting. It may also be used for confirmation purposes or recovery of overpaid funds.

Form #459-364w.pdf (10/21/2009) SL3 IIM Code: 2163                        Page 1 of 4
Name:                                                                        Social Security number:

Section C: Beneficiary election (cont.)
Part 2: Beneficiary for (Non-Survivorship) Option 1, Refund Annuity, 15-Year Certain, Lump-Sum
        Option 1, or Total Lump-Sum Option
You can choose either the standard designation or you can specifically name your beneficiary(ies) if you
chose Option 1, Refund Annuity, 15-Year Certain, Lump-Sum Option 1, or Total Lump-Sum Option.
• If you elect the specific retiree beneficiary designation and/or name more than one beneficiary, indicate
  how much of the amount due (in percentages) you would like to go to each person or entity you named.
• If you have selected Option 1, Lump-Sum Option 1, or the Total Lump-Sum option, your beneficiary will
  receive your account balance if you die before your first payment is due.
Check only one box below.
C2a.  I elect to use the Standard Beneficiary designation. Do not complete C2b below. See Appendix E in the
PERS Pre-Retirement Guide for order of beneficiaries.
 C2b.  I elect to use the Specific Retiree Beneficiary designation.
 Full given name of beneficiary                                   Relationship                                               Percentage




Section D: Spousal consent and single member acknowledgement (required)
Choose one of the boxes below, and follow the corresponding instructions.
As of my effective retirement date, I am married.
If you are married, both you and your spouse must sign the applicant signature line and spouse signature
line in front of a notary. Your spouse is consenting to the option you selected in Section B and the beneficiary
you named in Section C.
As of my effective retirement date, I am single.
If you are single, sign the applicant signature line in front of a notary. We cannot pay benefits without
notarization.





                                                                               




      Applicant signature (do not print)                Date                       Spouse signature (do not print)                   Date
                                 Notary Public                                                                   Notary Public




                            Use space for seal                                                              Use space for seal
State of                               County of                                State of                               County of


Signed before me on this date:        Applicant name                            Signed before me on this date:         Spouse name


By (notary’s signature)               My commission expires                     By (notary’s signature)               My commission expires




Form #459-364w.pdf (10/21/2009) SL3 IIM Code: 2163             Page 2 of 4
Name:                                                                         Social Security number:

Section E: Lump-sum distribution installments
You can receive your lump sum in one, two, three, four, or five annual payments. Check the appropriate box
below to indicate how many installments you want to receive, and then enter the percentage you want for each
installment. The total must equal 100 percent.

 100%
 Two installments       1st         % + 2nd               % = 100 percent
 Three installments 1st             % + 2nd               % + 3rd              % = 100 percent
 Four installments      1st         % + 2nd               % + 3rd              % + 4th           % = 100 percent
 Five installments      1st         % + 2nd               % + 3rd              % + 4th           % + 5th           % = 100 percent

Section F: Lump-sum payment destination
Select one of the three sections below, and provide all information within that section (F1, F2, or F3).

F1. Send installment(s) directly to me.
F2. Send my installment(s) to a Traditional IRA Roth IRA.
     Roll over 100 percent of my payment.
    Roll over $ ,               ,          .       of my payment.
Send my installments to:
The custodian or trustee of my IRA: ________________________________________________________________
                                                 (custodian/trustee name)

 Account number (if available)


Address                                   City                          State        Zip+4 code                  Phone number


F3. Send my installment(s) to another eligible employer plan or deferred compensation plan. 
     Roll over 100 percent of my payment.
      Roll over $ ,          ,          .        of my payment.
Note: You must have the authorized representative of the plan complete the Direct Transfer Rollover
     Acceptance form.

 Section G: Variable election
If you have a variable account, do you want to continue to participate in it after retirement? Yes No
 Section H: Acknowledgement of receipt of Federal Tax Information Disclosure (required)
            and federal tax 30-day waiver (optional)
By signing below, I acknowledge I have read and understood Part Four, Tax Information of the PERS
Pre-retirement Guide.

 I waive my right to the 30-day period for reviewing the Federal Tax Information Disclosure. (optional)
 




     Applicant signature (do not print)                      Date




Form #459-364w.pdf (10/21/2009) SL3 IIM Code: 2163              Page 3 of 4
Name:                                                                                   Social Security number:

Section I: Authorization agreement for automatic deposits (ACH Credits)

First name                                    Middle initial                       Last name                        Phone number (with area code)


Mailing address (street or PO box number)                                       City                        State             Zip+4 code


To sign up for direct deposit, simply complete this authorization. You must check the type of account (checking
or savings), and sign and date this authorization. If you want your direct deposit to go to your checking account,
attach a voided or canceled check. Do not attach a deposit slip.
If you are authorizing PERS to directly deposit your monthly benefit into your checking account but do not
want to attach a voided or canceled check, or if you do not have printed personalized checks, please complete
the bottom half of this form.

Type of account (check one)                 Checking (Attach a voided or canceled check.)
                                            Savings (Do not attach a voided or canceled check.)
 Applicant certification - Required                                                 Joint account holder’s certification - Required
 I certify I have read and understand the information and                           I certify I have read this form and understand I must
 instructions on this form. In signing this form, I authorize                       advise PERS of the death of the above named applicant
 my payment to be sent to my financial institution and                              and that funds deposited into the account listed below
 deposited to the designated account. I authorize amounts                           after the date of death are to be refunded to PERS.
 transferred after my death or transmitted in error to be
 debited from my account. If the funds have been with-
 drawn following my date of death, I authorize my finan-
 cial institution to release the name and address of the                            Joint account holder name (please print)
 person(s) responsible for withdrawing the funds.





                                                                                   




     Signature of payee                                                                     Signature of joint account holder

 Date                                                                               Date



Name of financial institution                             Account number
                                                          (Show the number exactly, including necessary spaces, zeroes, or dashes.)



Branch name and number                                           Branch telephone number                    Routing number


Financial institution mailing address (street or PO box number)                           City                      State             Zip+4 code

                                                                                                                             Office use only
Attach your voided or canceled check here. (For checking accounts only.)                                             X PERS      OPSRP        IAP
Do not attach a deposit slip.                                                                                        Member  Alternate payee
                                                                                                                     Cross reference member SSN
Note: PERS can only deposit funds to banks in the United States. This
also applies to a direct deposit that will be transferred 100 percent into
a bank outside of the United States.
In compliance with the Americans with Disabilities Act, PERS will provide help filling out this form upon
request. You may request help by calling 503-598-7377, toll free 888-320-7377, or TTY 503-603-7766.
ORS: 238.660(4)
Form #459-364w.pdf (10/21/2009) SL3 IIM Code: 2163                        Page 4 of 4

                                                          Print Form                   Clear Fields
General instructions                                         How to fill out your SRA:
• You must be eligible to retire.                            Step-by-step instructions
• Type, fill out electronically, or print in dark ink.        Social Security box
                                                             Before filling out Section A, make sure you provide
• You must be separated from employment with PERS-
                                                             your Social Security number (SSN) and your PERS
 participating employers before your retirement date.
                                                             number in the boxes at the top right-hand side of the
• PERS must receive payment for waiting time,
                                                             application. If you do not know your PERS number,
 refunded time, and other purchases of service time          leave the PERS number box (located directly under
 credit before your effective date of retirement. Some       your SSN) blank.
 special, full cost purchases may be made after your
                                                             Note: Providing your SSN is mandatory, and PERS is
 effective retirement date.
                                                             authorized to request it under Internal Revenue code
• Generally, you have the right to change your option,       provisions. It will be used primarily to comply with
 beneficiary designation, or, if applicable, variable        mandatory IRS reporting. However, PERS may also
 participation within the first 60 days after the issue      use it internally for confirmation purposes or recovery
 date of the first benefit payment. Changes are retro-       of overpaid funds. (If you do not want it used for these
 active to your effective retirement date. For specific      purposes, enclose a written statement to that effect with
 limitations, see Your Guide to Retirement Options           your SRA.)
 on page 9 of the Pre-Retirement Guide.
                                                             Section A: Applicant information
• If there is a court-ordered lien on your account, op-      Fill in this section completely. Note: If you change your
 tion and beneficiary restrictions may apply.                mailing address after retirement, please notify PERS in
• Your application is not in effect until PERS receives      writing so you can receive important notices affecting
 and accepts it. PERS will mail you a letter confirm-        your benefits.
 ing receipt.                                                When you submit your application, you must also send us
• Return your application to PERS, and keep a copy           verification of age.
 for your records.                                           Verification of Age
• Make sure you sign and date all required areas. We         PERS must know your exact birth date to calculate your
                                                             retirement benefit. If you choose a survivorship option,
                              




 have used a pencil icon () to help you locate these
                                                             PERS must also validate your beneficiary’s birth date.
 places. Signatures are required for all lines marked
                                                             For a complete list of documents PERS can use as
          




 with a       . (You must sign in ink.)
                                                             verification of age, see Appendix A on page 21 of the
• You must have your signature notarized on page 2 of        Pre-Retirement Guide.
  your application. If you are married, your spouse must
                                                             PERS will not return these documents to you, so please
  also sign and have his or her signature notarized in the
                                                             provide legible photocopies along with your completed
 space provided on page 2. Applications must be signed
                                                             retirement application.
 and dated in front of a notary.
• Registered domestic partners, see page 6 of the
                                                             Citizenship
                                                             Check the appropriate box indicating whether or not you
 Pre-Retirement Guide for more information.
                                                             are a U.S. citizen. If you are not a U.S. citizen, indicate
• We recommend you send your SRA to us using
                                                             the country in which you are a citizen. PERS must know
 certified mail. We cannot be responsible for lost
                                                             your citizenship for tax purposes.
 applications.
Customer Service: 503-598-7377 or toll free 888-320-7377                                                                   1
Retirement date
Indicate the month and year you want your retirement
                                                           Section C: Beneficiary election
                                                           You must select a beneficiary. Fill out either Part 1 or
to begin. Retirements always begin on the first of the
                                                           Part 2. Part of your decision when choosing an option
month, so you only need to enter the month and the year.
                                                           involves selecting a beneficiary.
Your effective retirement date can be no sooner than
                                                           Different options have different beneficiary require-
either the first day of the month following the last day
                                                           ments because of the way they are paid out. Make
you worked (or were on qualifying paid leave) or the
                                                           sure your beneficiary designation is compatible with
first of the month following the month you file your
                                                           the option you selected. For more information, see
application for benefits, whichever is later. Example: If
                                                           Part Two: Your Guide to Retirement Options in the
your last day of work is June 5, 2008, your retirement
                                                           Pre-Retirement Guide for more information.
date could be no earlier than July 1, 2008; if your last
day worked was May 5, 2004, but you did not file your       If you have a complex situation, you may want to consult
                                                           with an estate planning attorney before filling out this part
application until August 6, 2008, your retirement date
                                                           of your application.
could be no earlier than September 1, 2008.
Please note the following restrictions:                    Section C: Part 1
 To change or establish a new retirement date, PERS       Fill out this section if you selected Option 2, 2A, 3, 3A,
    must receive a new retirement application and other    or Lump-Sum Option 2, 2A, 3, or 3A.
    retirement forms and documents as required by law      If you selected any of these options, you can name only
    before the issue date of your first benefit payment.   one beneficiary who will receive both a continuing
    If you change your retirement date, you must fill      monthly benefit and any unpaid lump-sum installments
    out a new SRA and any additional required forms.       if you selected a lump-sum option. You must provide
                                                           your beneficiary’s legal name, Social Security number,
 To cancel your retirement application, PERS must
                                                           date of birth, and your relationship to the beneficiary. If
    receive a written and signed cancellation request
                                                           you do not fill this section out completely, we will return
    before the issue date of your first benefit payment.
                                                           the application to you. This could delay your effective
    This request may be mailed or faxed to PERS at
                                                           retirement date.
    503-431-8292.
                                                           Section C: Part 2
Section B: Retirement options                              Fill this section out if you have chosen Option 1,
Important: We highly recommend you read and                Refund Annuity, 15-Year Certain, Lump-Sum Option
understand Part 2: Your Guide to Retirement Options        1, or the Total Lump-Sum Option. (Note: Even if you
before filling out this section. You cannot change         have chosen Option 1, you must name a beneficiary.
most options after 60 days from the date you receive       Under Option 1, if you die after retiring but before your
your first benefit payment.                                first benefit payment is due, your retirement benefits will
Once you decide which benefit option you want,             go to the beneficiary you name. Once your first benefit
check the box next to that option. You may only            payment is due, however, no payments will be made to a
choose one benefit option. If more than one box is         beneficiary.)
checked, we must return the application to you. This       Check box C2a if you want to use the Standard
could delay your effective retirement date.                Beneficiary designation. When you choose this



2                                                                         PERS website: http://oregon.gov/pers
beneficiary designation, you do not name any specific            Indicate whether you want to receive your lump-
person. Instead, your beneficiary selection follows the         sum balance in one, two, three, four, or five annual
order described in law.                                        installments, and then enter the amounts that correspond
                                                               with the number of years you want to receive the balance.
This is only available for Option 1 (and the member
                                                               For example, if you want to receive it in equal payments
dies prior to the date the first payment is due), Refund
                                                               over four years, enter 25% in the four boxes that follow
Annuity, 15-Year Certain, Lump-Sum Option 1, or Total
                                                               the box you checked, indicating you have elected four
(double) Lump-Sum Option.
                                                               installments.
Check box C2b if you want to name specific beneficiaries.
                                                               Percentages DO NOT have to be the same. For example,
You must list each beneficiary, your relationship to the
                                                               you can choose 50% the first year, 25% the next year,
beneficiary, and the percentage of your benefit that you
                                                               15% the following year, and 10% the fourth year. How
want to go to each person or entity you named. If you
                                                               much you receive each year is up to you.
want to have multiple beneficiaries share equally and have
rights of survivorship, write the word “and” between each      Make sure the figures you enter total 100%. If they do
beneficiary’s name. See Appendix C, page 22 of the Pre-         not, we will return your application to you. This could
Retirement Guide, for an example of “specific retiree           delay your effective retirement date.
designation of beneficiary.”
                                                               Section F: Lump-sum payment destination
Section D: Spousal consent and single                          If you select a lump-sum option, you must decide if you
member acknowledgement                                         want the portion eligible for rollover paid directly to
This section is required.                                      you or rolled over to an IRA, Roth IRA, or an eligible
                                                               employer plan.
Check the box on the first line of this section to indicate
your marital status.                                           Contributions on which you have already paid taxes,
                                                               if any, are eligible to be rolled over and will be mailed
Married members
                                                               directly to you.
You and your spouse must both sign this section. Both
signatures must be notarized.                                  If you want your lump-sum payment sent directly to
                                                               you, check box F1 in this section.
If you do not do this, your option will default to Option 3.
                                                               If you want to roll over part or all of your lump-sum
Registered Domestic Partners
                                                               payment to a traditional IRA or Roth IRA, check the
See page 6 of the of the Pre-Retirement Guide for
                                                               appropriate box in F2, and fill out the information that
more information on spousal consent for registered
                                                               directs us where to send your installments.
domestic partners.
                                                               If you choose to send part or all of your rollover
Single members
                                                               payment to an eligible employer plan or to a deferred
You must sign the applicant signature line. Your signature
must be notarized. If you do not do this, we will return       compensation plan, check the appropriate box in F3.

your application to you. This could delay your benefit          Section G: Variable election
payment.                                                       If you are currently participating in the variable account,
                                                               indicate whether you want to continue to participate in it
Section E: Lump-sum distribution
                                                               after retirement by checking the appropriate box in this
installments
                                                               section.
You must allocate the percentages for each payment of
your lump-sum balance.                                         This portion of the monthly retirement benefit may later

Customer Service: 503-598-7377 or toll free 888-320-7377                                                                     3
increase or decrease annually as the result of gains or        Guide for information on where the routing and account
losses from investments of the variable annuity account        numbers are located on your checks. Do not attach a
portfolio (stocks). You may change your variable annuity       deposit slip—the bank will not accept these.
election any time between your original election and
                                                               Because PERS must coordinate with your financial
within 60 days after the issue date of your first actual
                                                               institution, your first monthly check may be mailed to
benefit payment. Once this 60 days has elapsed, you may
                                                               you. Future changes to your account number may also
make no changes to your variable annuity election.
                                                               result in a monthly check mailed directly to you. All
If you elect a lump-sum settlement, your variable account      payments other than your monthly benefit will be mailed
will be automatically transferred to your regular account at   to you. Therefore, you should always provide PERS with
retirement.                                                    a current mailing address.

Section H: Acknowledgement of receipt                          An information stub will be mailed annually in December
of federal tax information                                     to your current mailing address. A special stub will be sent
You must be informed of federal tax laws that can              to you if your benefit or deduction amount is changed.
affect your distribution. Please read Part Four: Tax
                                                               Additional forms
Information of this guide. Your signature in Section H
                                                               Before submitting your application, please fill out any
of the SRA acknowledges you have read and understand
                                                               additional forms that may be required based on the
the information on PERS benefits and federal taxes. You
                                                               choices you have made.
must sign and date the applicant signature line. If you
do not, we will return the application to you. This could      These forms include:
delay your effective retirement date.                          Tax packet
                                                               We cannot process your application until we receive all
Section I: Authorization agreement for
                                                               necessary tax forms. This packet includes a number of
automatic deposits
                                                               forms that may apply to you, including the IRS form
Fill out this section if you want your retirement benefit
                                                               W-4P, the Acknowledgement of Receipt of Federal
deposited directly into your bank account.
                                                               Tax Information Disclosure form, and the Lump-Sum
PERS encourages you to have your benefit payment                Distribution Withholding Election form*.
deposited directly to your bank or other financial
institution for the following reasons:                         Direct Transfer Rollover Acceptance
• the deposit is always on time rather than depend-            If you are rolling your benefit over to another qualified
    ing on mail delivery;                                      retirement plan or deferred compensation plan, you must
• there is no risk of your benefit payment being                complete this form. An authorized representative of the
    stolen or lost; and                                        plan must sign the form.
• if you are on vacation, you will not have to
    arrange for someone else to deposit your benefit.           * The Lump-Sum Distribution Withholding Election form
Note: If you use automatic deposit for your monthly            is required for lump-sum distributions sent directly to
check and you receive more than one monthly check              members.
from PERS, all of your PERS accounts will be changed             Congratulations! Your application is now
to this account number.                                        complete. Please use the checklist to make sure
Please attach a voided check if you have one available.         you have completed all the required sections
If not, see Appendix D, page 23 of the Pre-Retirement                    and accompanying forms.

4                                                                            PERS website: http://oregon.gov/pers

				
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