Form R0890d - Retirement Application For Spousal Benefits Page 2
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2Name: ______________________________
SSN or Member ID: ____________________
Michigan National Guard State Military
Retirement Application for Spousal Benefits (continued)
Michigan Tax Withholding – Your Michigan military pension is exempt from Michigan income tax.
5. Check here if you do not want any Michigan income tax withheld from your monthly pension. If you check this box, make sure you
sign in Section V below (don’t complete lines 6-11 below).
Check only ONE box below. For joint filers, select the box for the age of the older spouse.
6. Check here if you (or your spouse) were born before 1946. If checked, your pension is exempt from Michigan income tax.
7. Check here if you (or your spouse) were born between 1946 and 1952. If checked, the first $20,000 of Michigan non-military
pension benefits ($40,000 if married) will be subtracted from your taxable income.
8. Check here if you (or your spouse) were born after 1952. If checked, your Michigan non-military pension is taxed at the current rate.
9. Enter number of personal and dependent exemptions you are claiming. Only claim each exemption once, even if you submit more
than one Michigan withholding form. ……………………………………………………………………………………………………………
(exemptions)
10. What is your Michigan withholding status? (Required)
Single
Married
Married but withhold at higher “Single” rate
11. Dollar amount, if any, you want withheld from each pension payment in addition to your standard Michigan withholding
amount. You must enter a number on line 9 (including 0) BEFORE you fill out line 11.
$ _________
Section IV – Enrolling in Direct Deposit
Record your direct deposit account information below.
By submitting this completed form, I authorize ORS to deposit my net monthly pension directly into the designated financial institution(s) and account(s).
This authorization remains in effect until canceled by: a) me; b) my death or legal incapacity; c) the financial institution; or d) the state of Michigan.
Financial Institution and Account Designation
You can have your pension payment sent electronically to one or two accounts, either at the same or different financial
institutions. Provide all of the information requested below. The bank’s routing number is usually the 9-digit number found in
the bottom left corner of your checking account check; your account number is the other set of digits that doesn’t match the
check number. Call your bank if you need help.
NAME OF FINANCIAL INSTITUTION #1
INSTITUTION’S TELEPHONE NUMBER
(
)
FINANCIAL INSTITUTION MAILING ADDRESS
CHECK ONLY ONE
CHECKING
SAVINGS
INSTITUTION #1 PENSION AMOUNT
CITY, STATE, ZIP
________% OR $__________
BANK ROUTING NUMBER (CANNOT START WITH “5”)
ACCOUNT NUMBER
NAME OF FINANCIAL INSTITUTION #2 (If this is the same as Institution #1, write “SAME” below.)
INSTITUTION’S TELEPHONE NUMBER
(
)
FINANCIAL INSTITUTION MAILING ADDRESS
CHECK ONLY ONE
CHECKING
SAVINGS
INSTITUTION #2 PENSION AMOUNT
CITY, STATE, ZIP
Balance of Pension
BANK ROUTING NUMBER (CANNOT START WITH “5”)
ACCOUNT NUMBER
Section V: Certification
By my signature below, I certify my spouse met the required eligibility of having served 19 years, 6 months, and 1 day in the
Michigan National Guard, was at least 55 years old at the time of death, and all of the above statements and attached documents are
true and correct. I wish to apply for survivor retirement benefits with the Michigan National Guard.
I also authorize the selections made in the Income Tax Withholding Authorization and my designation(s) for direct deposit. By using
direct deposit, I authorize ORS to recover money electronically deposited in my account(s) in error, either by adjusting the account(s)
or withholding any future payments. I understand I will be notified in writing if adjustments are made.
Applicant Signature: _________________________________________________________ Date: ___________________
Return application and all required documents to: ORS, P.O. Box 30171, Lansing MI 48909-7671
R0890D (Rev. 4/2014)
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