Form 20 - Election For Monthly Cost-Of-Living Adjustment - Public Employees' Retirement System Of Mississippi

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Election for Monthly Cost-of-Living Adjustment

Form 20 – Revised 12/1/2013

This form must be received by PERS on or before June 1 to be applicable for the following fiscal year. Please print or type in black ink.

Completed form should be mailed or faxed to PERS. See bottom of form for contact information.

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Benefit Recipient Information

–

PERS will automatically update the mailing address on file with the mailing address listed below

First Name: _____________________________________ MI: _________ Last Name: ______________________________________________________

Mailing Address: ________________________________________________ City: ___________________________ State: _______ Zip: _____________

Social Security No.: _______________________________E-Mail: _______________________________________________________________________

Phone: ________________________________  Cellular  Home  Work Phone: _______________________________  Cellular  Home  Work



Retirement Plan

Select applicable plan.

–

 Public Employees’ Retirement System of Mississippi (PERS)

 Mississippi Highway Safety Patrol Retirement System (MHSPRS)

 Supplemental Legislative Retirement Plan (SLRP)

 Municipal Retirement Systems (MRS) City: ________________________________



Account Information

– Indicate type of account selected in Section 2. If you receive more than one benefit from a retirement system or plan

administered by PERS, you must complete a separate election form for each account.

 Retiree Account

 Beneficiary Account



Cost-of-Living Adjustment (COLA) Payment Authorization

– Election of a monthly COLA payment is an irrevocable election. Once the

method of payment selected here begins, no other option will be available. If no option is selected here, COLA benefits will be paid in a lump sum each

December.

Select one.



As a benefit recipient of PERS, SLRP, or MHSPRS, or a Municipal Retirement Systems benefit recipient from Biloxi, Gulfport, or McComb, I elect, upon

eligibility, to receive my COLA in 12 equal monthly installments beginning in July of each year.



As a Municipal Retirement Systems benefit recipient from Clinton, Columbus, Greenville, Hattiesburg, Pascagoula, Vicksburg, or Yazoo City, I elect,

upon eligibility, to receive my COLA in equal monthly installments beginning in January as follows:

Select one:  Two consecutive months

 Three consecutive months

 Four consecutive months

 Five consecutive months