Form 29211 - Request For Estimate Of Benefits (Page 2 of 4) in pdf

STEP 1: Member Information

Member’s Social Security Number: Enter all nine digits of your Social Security Number. Your form will not be

processed without this information.

Member’s Date of Birth: Enter your date of birth as MM/DD/YYYY. If you have not previously furnished proof of

your age to PERF, you must submit such documentation along with this form. If you select Option 30, 40 or 50, you

are also required to furnish proof of age for your beneficiary. Documents showing the date of birth such as a certified

photocopy of a birth certificate, a baptismal or confirmation certificate, or a court decree are acceptable. Attach an

English language translation to any foreign language document.

Member’s Name: Enter your first name, middle initial, and last name(s).

Member’s Mailing Address: Enter your full street address, including apartment number or P.O. Box number, if

applicable to which you would like your estimate sent.

City: Enter the city to which you would like your estimate sent.

State: Enter the state to which you would like your estimate sent.

ZIP Code: Enter your five or nine-digit ZIP code.

Member’s Phone Number: Enter your telephone numbers, beginning with area code. Please provide separate day

and evening phone numbers.

E-mail address: Enter your E-mail address, if you have one.

STEP 2: Retirement Information

Please complete the line for retirement or disability benefits. DO NOT complete both.

Regular/Early Retirement Benefits

Anticipated Last Day at Work: Enter your anticipated last day at work as MM/DD/YYYY.

Disability Benefits

Social Security Onset Date: Enter the onset date for your disability assigned by the Social Security

Administration as MM/DD/YYYY. If you have not already provided PERF with a copy of your Social

Security disability award letter, you will need to include a copy with this form.

Anticipated Beginning Date of Retirement Benefits: Enter the beginning date of your retirement as MM/01/YYYY.

This date cannot be earlier than the first day of the month after your last in a pay status with your employer, or the

first day of the month after the disability onset date assigned by the Social Security Administration. For example, if

your last day in a pay status with your employer is January 1st, the earliest benefits can begin is February 1st. If your

last day in a pay status with your employer is January 31st, the earliest benefits can begin is February 1st.

Also, if your last day in a pay status with your employer was more than six months ago, then this effective date

cannot be prior to six months before PERF receives your completed retirement application.

STEP 3: Anticipated Retirement Beneficiary Information

Please provide the following information for anyone you anticipate naming as beneficiary for one of the joint and

survivor options (Options 30, 40, or 50) at retirement. If you do not provide this information, no estimate will be

prepared for the joint and survivor options.

Beneficiary’s Social Security Number: Enter all nine digits of your beneficiary’s Social Security Number

Date of Birth: Enter your beneficiary’s date of birth as MM/DD/YYYY.

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Form 29211 - Request For Estimate Of Benefits Page 2