Benefit Information Request
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1
2Wisconsin Department
of Employee Trust Funds
801 W Badger Road
PO Box 7931
Benefit Information Request
Madison WI 53707-7931
1-877-533-5020 (toll free)
Fax 608-267-4549
etf.wi.gov
This is not an application for benefits nor a beneficiary designation.
Member Contact Information
Name (First, middle, last, former/maiden)
Member ID or Social Security number
Street Address
Birth date
(MM/DD/CCYY)
City
State
ZIP code
Telephone
(
)
Home:
WRS Employer
(
)
Work:
Signature
Date
(MM/DD/CCYY)
Request a Benefit Application:
Check the appropriate box(es) and provide the requested information.
Separation Benefit Application
You are only eligible for a separation benefit if you are:
Under age 55 (50 if protective);
You are over age 55 (50), but you began covered WRS employment after 1989, terminated employment prior to
April 24, 1998, and do not have some WRS service in five calendar years; or
You are over 55 (50), but you began WRS employment on or after July 1, 2011, and do not have five years of
WRS creditable service.
Last day of work or end of layoff/leave of absence:
(MM/DD/CCYY).
Retirement Annuity Estimate
Disability Annuity Estimate:
Estimates cannot be calculated without the information below
Is the disability is work-related?
Yes
No
and will only be provided 12 months in advance of your
anticipated termination date or benefit effective date. This
Last day worked: ______________ (MM/DD/CCYY)
does not commit you to retiring or beginning benefits on that
Last day paid after all accrued leave used:
date.
Active members: What is your anticipated termination date?
________________________
(MM/DD/CCYY)
Inactive members: What (future) date would you like to begin
your benefit?
_________________________________
(MM/DD/CCYY)
Co
mplete this section if requesting a retirement and/or a disability estimate:
Earnings: Members actively working in a WRS covered position must provide their estimated gross earnings below.
1.
Teachers, educational support staff and justices use fiscal year earnings (July 1 to June 30). All others use calendar
year (Jan. 1 to Dec. 31).
Calendar Year
Fiscal Year
Last year’s estimated earnings: 1/1/____ - 12/31/____ $___________
7/1/____ - 6/30/____ $___________
This year’s estimated earnings: 1/1/____ - 12/31/____ $___________
7/1/____ - 6/30/____ $___________
Military Service: Do you have active military service prior to January 1, 1974?
Yes
No
2.
If yes, send a copy of your military discharge papers with this request (i.e., DD-214) if you have not previously done so.
Named Survivor: This information is needed to calculate joint and survivor estimates and is not a beneficiary
3.
designation. Name:
Birth date:
Relationship to member: ____________________________
(MM/DD/CCYY)
Use the reverse side to request other information, report a member death or request death benefit information.
ET-7301 (REV 1/20/2016)
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