Fillable Retirement Plan Election Form - Strs Ohio printable pdf download

RETIREMENT PLAN ELECTION FORM

You will have 120 days from your first day of paid service to complete and return this election form to the Human Resources Department at your institution. If

you want to become a member of an Ohio state retirement system, simply check the appropriate box in Section 2 below. If you want to participate in an alternative

retirement plan (ARP) offered by a private plan provider, check the appropriate box in Section 2 below and select one of the plans. If you do not elect to participate

in an ARP or do not return this form within the prescribed time period, you will be enrolled in the applicable state retirement system.

Section 1 — Biographical Information (Please print or type.)

Name ___________________________________________________________

Social Security no. _________________________________

First

Middle initial

Last

–

Address __________________________________________________________

Phone number _____________________________________

Area code

____________________________________________________________ Birth date _________________________ Gender _________

City

State

ZIP code

Employee identification number _______________________________________

Hire date __________________________________________

If applicable

Are you receiving a retirement benefit from one of these Ohio retirement systems: HPRS, OPERS, OP&F, SERS or STRS Ohio? ❏ Yes

❏ No

If “Yes,” which system? _____________________________________________

Effective date of retirement ___________________________

Section 2 — Election (Choose only one.)

❏

I elect to participate in the

❏

I elect to participate in an ARP: (Select only one of the following ARP carriers. You must

state retirement system for

contact your chosen carrier to enroll.)

which I am eligible.

❏ AIG VALIC

❏ Lincoln Financial Group

• OPERS*

• SERS

❏ AXA Equitable Life Insurance Co.

❏ MassMutual Financial Group

• STRS Ohio*

❏ Fidelity Investments

❏ Nationwide Life Insurance Co.

I understand that I may not change my election to

❏ Voya Financial

❏ TIAA

participate in the state retirement system after my

election period expires and that my election will be

I understand that by electing to participate in an ARP I am irrevocably waiving my right to participate

irrevocable while I am continuously employed in a

in the eligible state retirement system while I am continuously employed in a position at my college or

position at my current college or university.

university. I also understand that by electing to participate in an ARP offered by a private plan provider,

I will be forever barred from claiming or purchasing service credit or participating in other plans offered

*Eligible employees may be able to participate in a defined

by any state retirement system for the period that an election to participate in an ARP is effective.

contribution plan. Contact your applicable retirement system for

more information about these plans and eligibility.

Section 3 — Authorization

I hereby certify the election chosen above in Section 2. I understand that I will be able to make an election to participate in another ARP or Ohio public

retirement system if I cease to be continuously employed or am subsequently employed full time by another Ohio public institution of higher education

in a position for which a retirement election is available.

______________________________________________________________________________________

_______________________

Employee’s signature

Date

OFFICE OF HUMAN RESOURCES USE ONLY

❏

Applicable state system

OPERS

SERS

STRS Ohio