Spousal Consent Form - Public Employees Retirement Association Of Nm
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33 Plaza La Prensa, Santa Fe, New Mexico 87507
(505) 476-9401 fax
(505) 476-9300 voice
(800) 342-3422 Toll-Free
SPOUSAL CONSENT FORM
Instructions: Please print or type in dark ink. The original of this form must be completed in its entirety and returned to PERA for
BOLD ITALICS
processing. Required Fields are in
. Additional instructions are on the back.
No correction fluid will be allowed on this form.
SPOUSE
S INFORMATION AND NOTARIZATION – In The Presence Of A Notary
I, _______________________________________________________ , spouse of
(Spouse’s Name)
(please print)
_________________________________________________________ consent to his/her decision to receive
(Retiree’s Name)
(please print)
benefits under Form of Payment ________ with __________________________________ named as survivor beneficiary.
(Beneficiary’s Name)
(please print)
I understand that I will not be entitled to survivor benefits unless I have been listed on the Final Application for Annuity as
the beneficiary under either Form of Payment B or C.
______________________________
___________________________________________
Date
Signature of Retiree’s Spouse
State of New Mexico
)
SS
)
:
County of
___________________
)
Signed and sworn to (or affirmed) before me by ______________________________________ on this the
day of
________
(Spouse’s Name)
(please print)
________________, _______.
My Commission Expires
___________________________
Notary Public Telephone No ______-______-_________
Notary Signature __________________________________
NOTARIZATION OF RETIREE
S SIGNATURE – In The Presence Of A Notary
____________________________________________
_____________________________________________
Signature of Retiree
Retiree’s Social Security Number or PERA ID Number
____________________________________________
_____________________________________________
Retiree Name
Date
(please print)
State of New Mexico
)
SS
)
:
County of
___________________
)
Signed and sworn to (or affirmed) before me by _____________________________________ on this the
day of
_______
(Retiree’s Name)
(please print)
______________________, _______.
My Commission Expires
___________________________
Notary Public Telephone No ______-______-_________
Notary Signature __________________________________
Instructions on back
PERA Rule 2.80.700.10.B (3)NMAC requires that the retiring member provides PERA with court endorsed copies of all divorce orders and
marital settlement agreements entered after the first PERA membership application is filed.
The member should return the completed Application for Pension with all required documentation to PERA at least sixty (60) calendar days
prior to the selected date of retirement. If the member does not specify a form of payment prior to their retirement date, the retirement
application will be processed according to NMSA 1978, Section 10-11-116 A(1)(2004). This section of the state statute requires payment to be
made under Form of Payment A if there is no eligible spouse or under Form of Payment C if there is an eligible spouse. If payments are to be
made under Form of Payment C according to this section, the eligible spouse will be designated as the survivor beneficiary.
No correction fluid will be allowed on this form.
September 2015
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