Form 18-Service Retirement Application Form-Hawaii Employees' Retirement System Page 3
Download a blank fillable Form 18-Service Retirement Application Form-Hawaii Employees' Retirement System in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form 18-Service Retirement Application Form-Hawaii Employees' Retirement System with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3EMPLOYEES’ RETIREMENT SYSTEM
Form 18
OF THE STATE OF HAWAII
Rev. 8/2016
201 M
S
, S
1400, H
, H
96813-2980
ERCHANT
TREET
UITE
ONOLULU
AWAII
Phone: (808) 586-1735 Fax: (808) 587-5766
Clear Form
SERVICE RETIREMENT APPLICATION
To the Board of Trustees:
Date _________________________, 20____
In accordance with the provisions of law governing the operation of the Employees’ Retirement System (ERS) of the State of Hawaii, the
undersigned, a member of ERS, hereby applies for service retirement.
I. PERSONAL DATA: (Please print or type)
Name: _________________________________________________________Social Security Number: ____________________________
LAST
FIRST
MI
Mailing or PO Box Address: _____________________________________________________________________________________
STREET
APT. NO
CITY
STATE
ZIP CODE
Retirement Date: _______/_______/_______
Date of Birth: _______/_______/_______
Marital Status: [ ] Single [ ] Married
MONTH
DAY
YEAR
MONTH
DAY
YEAR
Position Title__________________________________ Department/Division or School: _____________________________________
Employer: (Check one)
[ ] State of Hawaii
[ ] County of ________________________
[ ] Board of Water Supply
Contact Phone: ______________________ [ ] Home [ ] Cell [ ] Work
Email Address : __________________________________
II. RETIREMENT OPTIONS: I have read the information on selecting a retirement option and I select the following retirement option.
[ ] HYBRID
[ ] NONCONTRIBUTORY
[ ] CONTRIBUTORY
____ Maximum Allowance
____ Maximum Allowance
____ Maximum Allowance
____ Option One
____ Option A (50% Survivor)
____ Option One
____ Option Two (100% Survivor)
____ Option B (100% Survivor)
____ Option Two (100% Survivor)
____ Option Three (50% Survivor)
____ Option C (10-Yr Guarantee)
____ Option Three (50% Survivor)
Refund options below are only available to Hybrid/Contributory Members with at least 10 years of credited service.
____ Option Four (Five & ____) Refunds:
___Pre-1987
___50%
___75% (Contributory only)
____ Option Five (100% Refund)
III. BENEFICIARY DESIGNATION: A beneficiary must be designated for all options, however, only one beneficiary may be designated
for Hybrid/Contributory options Two, Three, Four (5 & 2) and Four (5 & 3) and Noncontributory options A, B, or C.
Multiple beneficiaries, a trust, or an estate may be designated for all other options.
Name: ______________________________________________________Social Security Number: ___________________________
LAST
FIRST
MI
Relationship: ________________________________________________________Date of Birth: _________/_________/________
MONTH
DAY
YEAR
IV. SIGNATURE: This application must be signed in the presence of an ERS representative or a Notary Public.
Signed___________________________________________________Date_________________ERS Representative______________
State of Hawaii
)
____________County of ______________________________) SS.
On the ______ day of _________________________, 20______ personally appeared before me the said named
________________________________________ to me known to be the person described in and who executed the foregoing instrument
and who acknowledged such execution as being a free and voluntary act and deed.
______________________________________________________
Affix your
Notary Public
__________________________________________
official seal
My commission expires
__________________________________
Notary Public Certification
Doc. Date:_________________________
No. of Pages: 1
Document Description: Service Retirement Application
Notary Name: ________________________________________ Circuit: ___________________
Affix your official seal
Notary Signature:______________________________________
Date:_____________________
WHITE – ERS Copy
YELLOW – Member’s Copy
ADVERTISEMENT
0 votes
Related Articles
Related forms
Dd Form 2937 - Election Of Retirement Coverage For Reemployed Civil Service Retirement System (csrs) And Csrs-offset Discontinued Service Retirement (dsr) Annuitants
Business
Form 02-05 Lasers Louisiana State Employees' Retirement System - Certification For Purchase Of In-state Service
Legal
Related Categories
Parent category: Legal