Form PERS-BSD-800A "Justification for Absence of Spouse's or Registered Domestic Partner's Signature" - California

What Is Form PERS-BSD-800A?

This is a legal form that was released by the California Public Employees' Retirement System - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2019;
  • The latest edition provided by the California Public Employees' Retirement System;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form PERS-BSD-800A by clicking the link below or browse more documents and templates provided by the California Public Employees' Retirement System.

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Download Form PERS-BSD-800A "Justification for Absence of Spouse's or Registered Domestic Partner's Signature" - California

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Justification for Absence of Spouse’s
or Registered Domestic Partner’s Signature
888 CalPERS (or 888-225-7377)
TTY: (877) 249-7442
Member Information
Section 1
Name of Member (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
Pursuant to Government Code section 21261, an election of optional settlement, designation of beneficiary, or
change in beneficiary shall contain the signature of the current spouse or registered domestic partner unless the
retirement payment option provides him or her 100 percent of the member’s monthly allowance and he or she was
also named as the sole beneficiary for any lump-sum benefits.
If a spouse’s or registered domestic partner’s signature is required and he or she is unable to sign
the retirement application or beneficiary designation form, the following information must be completed
by the member.
By checking this box, I indicate that I am married or have a registered domestic partner, but my spouse
F
F
or registered domestic partner did not sign this form because:
I do not know and have taken all reasonable steps to determine the whereabouts of my spouse
F
F
or registered domestic partner; or
My spouse or registered domestic partner has been advised of the application and has refused
F
F
to sign the written acknowledgment; or
My spouse or registered domestic partner is incapable of executing the acknowledgment because
F
F
of an incapacitating mental or physical condition; or
My spouse or registered domestic partner has no identifiable community property interest
F
F
in the benefit; or
My spouse or registered domestic partner and I have executed a marriage settlement or partnership
F
F
agreement that makes the community property law inapplicable to the marriage or partnership.
Information Certification
Section 2
I certify under penalty of perjury that the foregoing information is true and correct.
Signature of Member
Date (mm/dd/yyyy)
Mail to:
CalPERS Retirement Benefit Services Division
P.O. Box 942711, Sacramento, California 94229-2711
PERS-BSD-800A (12/19)
Page 1 of 1
Justification for Absence of Spouse’s
or Registered Domestic Partner’s Signature
888 CalPERS (or 888-225-7377)
TTY: (877) 249-7442
Member Information
Section 1
Name of Member (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
Pursuant to Government Code section 21261, an election of optional settlement, designation of beneficiary, or
change in beneficiary shall contain the signature of the current spouse or registered domestic partner unless the
retirement payment option provides him or her 100 percent of the member’s monthly allowance and he or she was
also named as the sole beneficiary for any lump-sum benefits.
If a spouse’s or registered domestic partner’s signature is required and he or she is unable to sign
the retirement application or beneficiary designation form, the following information must be completed
by the member.
By checking this box, I indicate that I am married or have a registered domestic partner, but my spouse
F
F
or registered domestic partner did not sign this form because:
I do not know and have taken all reasonable steps to determine the whereabouts of my spouse
F
F
or registered domestic partner; or
My spouse or registered domestic partner has been advised of the application and has refused
F
F
to sign the written acknowledgment; or
My spouse or registered domestic partner is incapable of executing the acknowledgment because
F
F
of an incapacitating mental or physical condition; or
My spouse or registered domestic partner has no identifiable community property interest
F
F
in the benefit; or
My spouse or registered domestic partner and I have executed a marriage settlement or partnership
F
F
agreement that makes the community property law inapplicable to the marriage or partnership.
Information Certification
Section 2
I certify under penalty of perjury that the foregoing information is true and correct.
Signature of Member
Date (mm/dd/yyyy)
Mail to:
CalPERS Retirement Benefit Services Division
P.O. Box 942711, Sacramento, California 94229-2711
PERS-BSD-800A (12/19)
Page 1 of 1
Privacy Notice
The privacy of personal information is of the utmost importance to CalPERS.
The following information is provided to you in compliance with the Information
Practices Act of 1977 and the Federal Privacy Act of 1974.
Information Purpose
Social Security numbers are used for the
following purposes:
The information requested is collected pursuant
1.
Enrollee identification
to the Government Code (sections 20000 et seq.)
2. Payroll deduction/state contributions
and will be used for administration of Board
3. Billing of contracting agencies for employee/
duties under the Retirement Law, the Social
employer contributions
Security Act, and the Public Employees’ Medical
4. Reports to CalPERS and other state agencies
and Hospital Care Act, as the case may be.
5. Coordination of benefits among carriers
Submission of the requested information is
6. Resolving member appeals, complaints,
mandatory. Failure to comply may result in
or grievances with health plan carriers
CalPERS being unable to perform its functions
regarding your status.
Information Disclosure
Please do not include information that is
Portions of this information may be transferred
not requested.
to other state agencies (such as your employer),
physicians, and insurance carriers, but only
Social Security Numbers
in strict accordance with current statutes
regarding confidentiality.
Social Security numbers are collected on a
mandatory and voluntary basis. If this is CalPERS’
Your Rights
first request for disclosure of your Social Security
number, then disclosure is mandatory. If your
You have the right to review your membership
Social Security number has already been provided,
files maintained by the System. For questions
disclosure is voluntary. Due to the use of Social
about this notice, our Privacy Policy, or your rights,
Security numbers by other agencies for
please write to the CalPERS Privacy Officer at
identification purposes, we may be unable to
400 Q Street, Sacramento, CA 95811 or call us
verify eligibility for benefits without the number.
at 888 CalPERS (or 888-225-7377).
May 2016
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