Maryland State Retirement Agency - Application For Membership, Designation Of Beneficiary,

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MARYLAND STATE RETIREMENT AGENCY

120 EAST BALTIMORE STREET

BALTIMORE, MD 21202-6700

APPLICATION FOR MEMBERSHIP

FOR RETIREMENT USE ONLY

FORM 001 (REV. 9/10)

IMPORTANT: PLEASE PRINT CLEARLY AND READ THE INSTRUCTIONS FIRST.

APPLICANT'S SOCIAL SECURITY NUMBER

GENDER (M or F)

DATE OF BIRTH

–

Month

Day

Year

APPLICANT=S NAME

First

Initial

Last

HOME ADDRESS

Number and Street

City

State

Zip Code

–

Home Phone Number

Have you ever been a member of the Maryland State Retirement and Pension System? .............................................. Yes

Have you ever been a member of the Optional Retirement Plan (ORP)? ........................................................................ Yes

Are you presently receiving a retirement allowance from the Maryland State Retirement and Pension System? ............ Yes

Are you presently a member of another State or local retirement or pension system operated under the laws of

Maryland or any political subdivision of Maryland?........................................................................................................... Yes

IMPORTANT: If yes, read carefully the transfer provisions on the back of this form and then initial here: ________.

Have you attached acceptable proof of birth date as described on the back of this form?…………………………………….. Yes

I certify that all statements made on this application are correct. I authorize any required deductions from my salary at the prescribed rate.

And if I am presently a member of another State or local retirement or pension system, I have read and understand the transfer provisions.

Complete Signature

Date Signed

RETIREMENT COORDINATOR COMPLETES THIS SECTION

IS THE APPLICANT A PERMANENT EMPLOYEE? ....................................................................................................... Yes

If part-time, what percentage of time is the applicant employed? ...............................................................

percent

When did applicant begin present continuous service?........................................... Month

Day

Year

C. What is the applicant=s complete job classification or title?

D. Is applicant’s current position Optional Retirement Plan (ORP) eligible? ............................................................................ Yes

If yes and the applicant checked “Yes” to question 2 above, STOP and complete Form 60 Election Not to Participate in the

Teachers’/Employees’ System by Faculty or Administrative Officers of Institutions of Higher Learning.

What is the applicant=s annual salary? $

What is the applicant=s annual standard hours?

If applying for membership in the Law Enforcement Officers= Pension System, does the applicant meet the eligibility requirements?

......................................................................................................................................................................................... Yes

G. Number of pay periods reported per year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

INDICATE SYSTEM:

Teachers= Pension

Employees= Pension

Correctional Officers= Retirement

State Police Retirement

Law Enforcement Officers= Pension

FOR RETIREMENT USE ONLY

# OF RETIREMENT

CONTRIBUTIONS

EMPLOYING AGENCY CODE

DEDUCTED PER YEAR

SYSTEM