Form PERS09M0297 "Judges' Service Retirement Application" - California

What Is Form PERS09M0297?

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 May 1, 2016;
  • 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 printable version of Form PERS09M0297 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 PERS09M0297 "Judges' Service Retirement Application" - California

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P.O. Box 942705 Sacramento, CA 94229-2705
916-795-3688
TTY: (877) 249-7442 | Fax: 916-795-1500
www.calpers.ca.gov
Judges’ Retirement System
JUDGES’ RETIREMENT APPLICATION
Important: Your application should be mailed directly to the Judges’ Retirement System no more than 90 days
before your retirement date. Please forward your retirement application, together with a copy of your birth
certificate.
Section 1 – Judges’ Retirement System Member Information
_______________________________________________________________
___________________________
First Name
Middle Initial
Last Name
Social Security Number or CalPERS ID
_________________________________________________
Male
Female __________________________
Mailing Address
Date of Birth
(mm/dd/yyyy)
________________________________________________________________
(______)____________________
City
Home Phone
________________________________________________________________
(______)____________________
State
Zip Code
Country
Work Phone
Section 2 – Retirement Information
Current Court Type:
Supreme
Appellate
Superior
_______________________________________
____________________________________________________
Retirement Date
Last Day on Payroll -
County and/or District Name, or Appellate District & Division
(
mm/dd/yyyy)
_______________________________________
Allowance Commencement Date
(mm/dd/yyyy)
Other California Public Retirement Systems:
Yes
No If yes, complete the section below.
________________________________________________________________
__________________________
Name of System
Date of Retirement
(mm/dd/yyyy)
Date of Service Credited:_____________/_______/____________
____________/_______/____________
From
To
Section 3 – Survivor Continuance
____________________________________________
____________________
________-______-________
Spouse/Registered Domestic Partner’s Name
Social Security Number
__________________________________
_____________________________________
Male
Female
Date of Birth
Date of Marriage/Registered Partnership
(mm/dd/yyyy)
(mm/dd/yyyy)
PERS09M0297
Page 1 of 10
P.O. Box 942705 Sacramento, CA 94229-2705
916-795-3688
TTY: (877) 249-7442 | Fax: 916-795-1500
www.calpers.ca.gov
Judges’ Retirement System
JUDGES’ RETIREMENT APPLICATION
Important: Your application should be mailed directly to the Judges’ Retirement System no more than 90 days
before your retirement date. Please forward your retirement application, together with a copy of your birth
certificate.
Section 1 – Judges’ Retirement System Member Information
_______________________________________________________________
___________________________
First Name
Middle Initial
Last Name
Social Security Number or CalPERS ID
_________________________________________________
Male
Female __________________________
Mailing Address
Date of Birth
(mm/dd/yyyy)
________________________________________________________________
(______)____________________
City
Home Phone
________________________________________________________________
(______)____________________
State
Zip Code
Country
Work Phone
Section 2 – Retirement Information
Current Court Type:
Supreme
Appellate
Superior
_______________________________________
____________________________________________________
Retirement Date
Last Day on Payroll -
County and/or District Name, or Appellate District & Division
(
mm/dd/yyyy)
_______________________________________
Allowance Commencement Date
(mm/dd/yyyy)
Other California Public Retirement Systems:
Yes
No If yes, complete the section below.
________________________________________________________________
__________________________
Name of System
Date of Retirement
(mm/dd/yyyy)
Date of Service Credited:_____________/_______/____________
____________/_______/____________
From
To
Section 3 – Survivor Continuance
____________________________________________
____________________
________-______-________
Spouse/Registered Domestic Partner’s Name
Social Security Number
__________________________________
_____________________________________
Male
Female
Date of Birth
Date of Marriage/Registered Partnership
(mm/dd/yyyy)
(mm/dd/yyyy)
PERS09M0297
Page 1 of 10
_____________________________________________________ ________________________________________
Name
Social Security Number or CalPERS ID
Section 4 – Select Your Retirement Payment Option and Beneficiary
By filling out this section, you are electing your Retirement Payment Option and designating your beneficiary.
Once you select a payment option, you cannot change to another option. Along with your option selection, you
must complete at least one of the beneficiary designations in Sections 4a-4d. If you choose the Unmodified
Allowance Option, you do not need to specify a beneficiary. Select only one payment option.
 Option 1 – To complete this option, you must also fill out section 4d, Option 1 Balance of Contributions
Beneficiary.
 Option 2 – To complete this option, you must also fill out section 4a, Individual Lifetime Beneficiary.
 Option 2W – To complete this option, you must also fill out section 4a, Individual Lifetime Beneficiary.
 Option 3 – To complete this option, you must also fill out section 4a, Individual Lifetime Beneficiary.
 Option 3W – To complete this option, you must also fill out section 4a, Individual Lifetime Beneficiary.
 Unmodified Allowance Option – If you complete this option, there is no return of your member
contributions and no monthly benefits payable upon your death – except a survivor allowance, if applicable.
There is no beneficiary designation for this option.
 Option 4, Individual Lifetime Beneficiary – If you select this option, you must also select one of the
following Individual Lifetime Beneficiary options below.
Option 2W & Option 1 Combined – To complete this option, you must also fill out Section 4a, Individual
Lifetime Beneficiary and Section 4d, Option 1 Balance of Contributions.
Option 3W & Option 1 Combined - To complete this option, you must also fill out Section 4a, Individual
Lifetime Beneficiary and Section 4d, Option 1 Balance of Contributions.
Specific Dollar Amount to Beneficiary $_____________ - To complete this option, you must also fill out
Section 4a, Individual Lifetime Beneficiary.
Specific Percentage to Beneficiary _____________% - To complete this option, you must also fill out
Section 4a, Individual Lifetime Beneficiary.
 Option 4, Multiple Lifetime Beneficiaries – To complete this option, you must also fill out Section 4b,
Multiple Lifetime Beneficiaries.
 Option 4, Court Ordered Community Property – To complete this option, you must also fill out Section
4c, Court Ordered Community Property Beneficiary and select one of the following Court Ordered Community
Property options.
Option 4/Unmodified – There is no additional beneficiary designation for this option.
Option 4/1 - To complete this option, you must also fill out Section 4d, Balance of Contributions Beneficiary.
Option 4/2W - To complete this option, you must also fill out Section 4a, Individual Lifetime Beneficiary.
Option 4/3W - To complete this option, you must also fill out Section 4a, Individual Lifetime Beneficiary.
Page 2 of 10
_____________________________________________________ ________________________________________
Name
Social Security Number or CalPERS ID
Section 4a – Option 2, 2W, 3, 3W, or 4 Individual Lifetime Beneficiary
Complete this section only if you selected either Option 2, 2W, 3, 3W, or Option 4 Individual Lifetime Beneficiary
or Option 4/2W or 4/3W Court Ordered Community Property.
_________________________________________________________ _____________________________________
Name (First Name, Middle Initial, Last Name)
Social Security Number
_____________________
Male
Female
________________________________________________
Birth Date (mm/dd/yyyy)
Gender
Relationship to You
_______________________________________________________________________________________________
Address
________________________________
_______________________________________________________________
City
State
Zip
Country
Section 4b – Option 4 Multiple Lifetime Beneficiaries
Complete this section only if you selected Option 4 Multiple Lifetime Beneficiaries. If you want your beneficiaries
to receive an equal share of your benefits, do not specify a dollar or percentage of benefit.
_________________________________________________________ _____________________________________
Name (First Name, Middle Initial, Last Name)
Social Security Number
_____________________
Male
Female
________________________________________________
Birth Date (mm/dd/yyyy)
Gender
Relationship to You
Dollar/Percent of Benefit
_______________________________________________________________________________________________
Address
_______________________________________________________________________________________________
City
State
Zip
Country
_________________________________________________________ _____________________________________
Name (First Name, Middle Initial, Last Name)
Social Security Number
_____________________
Male
Female
________________________________________________
Birth Date (mm/dd/yyyy)
Gender
Relationship to You
Dollar/Percent of Benefit
_______________________________________________________________________________________________
Address
_______________________________________________________________________________________________
City
State
Zip
Country
________________________________________________________
_____________________________________
Name (First Name, Middle Initial, Last Name)
Social Security Number
_____________________
Male
Female
________________________________________________
Birth Date (mm/dd/yyyy)
Gender
Relationship to You
Dollar/Percent of Benefit
_______________________________________________________________________________________________
Address
_______________________________________________________________________________________________
City
State
Zip
Country
Page 3 of 10
_____________________________________________________ ________________________________________
Name
Social Security Number or CalPERS ID
Section 4c – Court Ordered Option 4 Community Property Beneficiary
Complete this section only if you selected Option 4 Court Ordered Community Property.
_________________________________________________________ _____________________________________
Name (First Name, Middle Initial, Last Name)
Social Security Number
_____________________
Male
Female
________________________________________________
Birth Date (mm/dd/yyyy)
Gender
Relationship to You
_______________________________________________________________________________________________
Address
_______________________________________________________________________________________________
City
State
Zip
Country
Section 4d – Option 1 Balance of Contributions
Complete this section only if you selected Option 1, Option 4-2W/1 or 4-3W-1 combined. You may change this
beneficiary(ies) at any time. This designation automatically revokes when there is a change in your marital
status, domestic partnership status, or when there is a birth or adoption of a child.
_________________________________________________________ _____________________________________
Name (First Name, Middle Initial, Last Name)
Social Security Number
_____________________
Male
Female
________________________________________________
Birth Date (mm/dd/yyyy)
Gender
Relationship to You
_______________________________________________________________________________________________
Address
_______________________________________________________________________________________________
City
State
Zip
Country
_________________________________________________________ _____________________________________
Name (First Name, Middle Initial, Last Name)
Social Security Number
_____________________
Male
Female
________________________________________________
Birth Date (mm/dd/yyyy)
Gender
Relationship to You
_______________________________________________________________________________________________
Address
_______________________________________________________________________________________________
City
State
Zip
Country
_________________________________________________________ _____________________________________
Name (First Name, Middle Initial, Last Name)
Social Security Number
_____________________
Male
Female
________________________________________________
Birth Date (mm/dd/yyyy)
Gender
Relationship to You
_______________________________________________________________________________________________
Address
_______________________________________________________________________________________________
City
State
Zip
Country
Page 4 of 10
____________________________________________________ ________________________________________
Name
Social Security Number or CalPERS ID
Section 5 – Member Signature and Notary
I hereby certify, under penalty of perjury, that the information submitted hereon is true and correct to the best of my knowledge.
I understand that to cancel this application, I must notify the Judges’ Retirement System before the mailing of my first retirement
allowance.
 I am not married/in a registered domestic partnership
__________________________________________
__________________________________________________________
Member’s Signature
Spouse/Registered Domestic Partner’s Signature
Date (mm/dd/yyyy)
Date (mm/dd/yyyy)
A notary public or other officer completing this
certificate verifies only the identity of the individual
who signed the document to which this certificate is
attached, and not the truthfulness, accuracy, or
validity of that document.
State of California, County of ______________________________________________________________________
On ____________________ before me, ____________________________________________________, personally appeared,
(Date-mm/dd/yyyy)
(Name & Title of Officer or CalPERS Representative)
_________________________________________________________ who proved to me on the basis of satisfactory evidence to
be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the
same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity
upon behalf of which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct.
WITNESS my hand and official seal.
Signature ______________________________________________ (SEAL)
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