Application For Pension Form printable pdf download

33 Plaza La Prensa, Santa Fe, New Mexico 87507

(505) 476-9401 fax

(505) 476-9300 voice

(800) 342-3422 Toll-Free

APPLICATION FOR PENSION FORM

Instructions: Please print or type in a dark ink. The original of this form must be completed

BOLD ITALICS

in its entirety and returned to PERA for processing. Required fields are in

GENERAL INFORMATION – PLEASE TYPE OR PRINT CLEARLY

SOCIAL SECURITY NUMBER or PERA ID NUMBER

NAME

LAST

FIRST

MAILING ADDRESS

CITY

STATE

ZIP

MARITAL STATUS

NEVER MARRIED

MARRIED

DIVORCED

WIDOWED

HAVE YOU BEEN DIVORCED?

Yes

If yes, please provide court endorsed copies of your divorce decree and

property settlement agreement(s) that happened while a PERA member. If the divorce happened prior to PERA membership and you

have not remarried, provide a copy of only the divorce decree. If you remarried prior to PERA membership and are still married to the

same person, you do not need to provide any divorce documentation.

DO YOU HAVE SERVICE CREDIT IN ANY OF THESE PLANS?

PERA

ERB

MRA

JRA

VFF

Legislative

LAST PERA AFFILIATED EMPLOYER

DATE OF BIRTH

EFFECTIVE TERMINATION DATE

PLANNED RETIREMENT DATE

Date you leave/left employment

First day of a month

BENEFICIARY DESIGNATION AND FORM OF PAYMENT

Upon retirement, you may select ONE of the following forms of payment of a pension. PERA will provide you with an estimate of your

benefits as requested below.

Form of Payment A: Straight Life Option. Provides a benefit to you for your lifetime. Payments stop upon your death.

Form of Payment B: Joint Survivor Option (100%). Provides a benefit to you for your lifetime with the same amount continuing for

life to your beneficiary upon your death.

Form of Payment C: Joint Survivor Option (50%). Provides a benefit to you for your lifetime with 50% of that amount continuing for

life to you beneficiary upon your death.

Form of Payment D: Temporary Joint Survivor Option (Children). Provides a benefit to you for life, with the same amount

continuing to your eligible children until each child reaches age 25. Provide beneficiary information for each child.

Magistrate - Judicial - Volunteer Firefighter: Survivor pension paid according to each specific statute.

BENEFICIARY SELECTION

If you chose Form of Payment A: Please name a refund beneficiary or organization below. Upon your death, if the total amount of

payments received is less than your total employee contributions, the difference will be refunded to your refund beneficiary or organization

specified below. If no refund beneficiary designation is on record, any employee contributions will be refunded to your estate.

If you choose Form of Payment B, C or D: please give us the full name, address, date of birth and relationship. If you are married on the

date of your retirement and do not name your spouse as survivor beneficiary, your spouse must consent in writing. You must submit

proof of age on yourself and your survivor beneficiary as well as marriage certificates or divorce decrees and property

settlement agreements. If Form of Payment D is desired, you must provide proof of age on each child under the age of 25.

FORM OF PAYMENT A ONLY – ORGANIZATION AS A REFUND BENEFICIARY

Organization Name

Address/Phone Number

Organization Tax ID Number

PERSON AS A REFUND OR SURVIVOR BENEFICIARY – FORM OF PAYMENT A, B, C & D. For Form of Payment D provide

beneficiary information for each child.

FIRST

LAST

Name

Relationship

Mailing Address

City

State

Zip

Beneficiary’s

Date of Birth

Social Security Number

CONTINUED ON PAGE 2

September 2015

Application For Pension Form

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