Form Psrs-151 - Request For Retirement Estimate

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Commonwealth of Pennsylvania - Public School Employees' Retirement System
5 N 5th Street
Request for
Harrisburg PA 17101-1905
Toll-Free: 1-888-773-7748
PSERS Health Insurance Program
Web Address:
Retirement Estimate
PSRS-151 (09/2012)
Complete this form only if your anticipated retirement date is within the next 12 months. See instructions on the reverse.
Social Security Number
Daytime Phone
Member Name
Address (Street, City, State, Zip)
Evening Phone
Email Address
Provide your current school year’s (July 1 – June 30) salary.
PSERS will project your final average salary based on the
Tentative Date of Retirement: _______________
information provided by you and your employer.
Current School Year’s Salary: _______________
Current Employment Status:
Survivor Annuitant:
Type of Estimate Request:
(See definitions on reverse.)
(check all that apply)
Active
Date of Birth _______________
Gender _______________
Regular
Unpaid Leave
Spouse /
Non-spouse
Disability
Terminated
(please check one)
Part-time members and members who are not retiring in June must complete the following:
Previous PSERS Retiree:
Number of days or hours from July 1 through June 30 that you expect to work in your final
school year of employment:
Yes _____
No _____
Days: _________
- OR -
Hours: __________
Your Signature:
Date Signed:
Upon completion, forward or fax this form to:
PSERS
5 N 5th Street
Harrisburg PA 17101-1905
FAX: 717-772-3860
REMINDERS:
Purchase of Service: If applicable, your completed application to purchase credit for service must be received by PSERS prior
to your last day of paid service. Please visit the PSERS website or request the “Let’s Talk About Purchasing Credit for Service”
pamphlet for more details.
An Application for Retirement must be filed with PSERS within 90 days of your date of termination for retroactive benefits.
Otherwise, your benefit will be effective the date your Application for Retirement is received by PSERS.
THIS FORM IS NOT AN APPLICATION FOR RETIREMENT.
FOR PSERS USE ONLY
Retirement Date:
Frozen Annuity: Yes / No
Years of Service:
Contributions:
Final Average Salary:
T-C _____
T-D _____
Total ________
Taxable ___________
Pre-87 ___________
Post-86 ___________
Debt: Purchase of Service/Overpayment/
Frozen Annuity
____________
CNW ___________
Interest ___________
Comments (divorce, MDIB, etc.):
Request for Retirement Estimate
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