"Judges' Retirement System Ii Application/Defined Benefit" - California

Judges' Retirement System Ii Application/Defined Benefit is a legal document that was released by the California Public Employees' Retirement System - a government authority operating within California.

Form Details:

  • Released on May 1, 2016;
  • The latest edition currently provided by the California Public Employees' Retirement System;
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  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the California Public Employees' Retirement System.

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Download "Judges' Retirement System Ii Application/Defined Benefit" - 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 II
Judges’ Retirement System II Application/Defined Benefit
Important: Your application should be mailed directly to the Judges’ Retirement System II no more than 120
days before your retirement date. Please forward your retirement application, together with a copy of your birth
certificate and all other required documents.
Section 1 – Judges’ Retirement System II 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
Country
Work Phone
Section 2 – Retirement Information
Current Court Type:
Supreme
Appellate
Superior
_________________________________________
________________________________________________
Retirement Date
County and/or District Name, or Appellate District & Division
(Last Day on Payroll - mm/dd/yyyy)
__________________________________________
Allowance Commencement Date
(mm/dd/yyyy)
Yes
No If yes, complete the section below.
Other California Public Retirement Systems:
_____________________________________________________________________________________________
Name of System
Date of Retirement
(mm/dd/yyyy)
_________/_________/_________
To: __________/_________/_________
Date of Service Credited From:
Month
Day
Year
Month
Day
Year
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)
Page 1 of 9
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 II
Judges’ Retirement System II Application/Defined Benefit
Important: Your application should be mailed directly to the Judges’ Retirement System II no more than 120
days before your retirement date. Please forward your retirement application, together with a copy of your birth
certificate and all other required documents.
Section 1 – Judges’ Retirement System II 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
Country
Work Phone
Section 2 – Retirement Information
Current Court Type:
Supreme
Appellate
Superior
_________________________________________
________________________________________________
Retirement Date
County and/or District Name, or Appellate District & Division
(Last Day on Payroll - mm/dd/yyyy)
__________________________________________
Allowance Commencement Date
(mm/dd/yyyy)
Yes
No If yes, complete the section below.
Other California Public Retirement Systems:
_____________________________________________________________________________________________
Name of System
Date of Retirement
(mm/dd/yyyy)
_________/_________/_________
To: __________/_________/_________
Date of Service Credited From:
Month
Day
Year
Month
Day
Year
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)
Page 1 of 9
_____________________________________________________ ________________________________________
Name
Social Security Number or CalPERS ID
Section 4 – Select Your Retirement Payment Option
By filling out this section, you are electing your retirement payment option and designating your
beneficiary. Your beneficiary may only be your spouse/registered domestic partner. Along with your
option selection, you must complete at least one of the Sections 4a-4b, naming your spouse/registered
domestic partner. If you choose the Unmodified Allowance Option, you do not need to specify your
spouse/registered domestic partner. Select only one payment option.
There is no beneficiary designation for this option
 Unmodified Allowance Option
and there is no return of contributions. Skip to
Section 5.
Complete your beneficiary designation in Section 4b
 Return of Remaining Contributions
Option 1
Complete your beneficiary designation in Section 4a
 100 Percent Beneficiary Option 2 with
Benefit Allowance Increase
Complete your beneficiary designation in Section 4a
 100 Percent Beneficiary Option 2
and 4b
Complete your beneficiary designation in Section 4a
 50 Percent Beneficiary Option 3 with
Benefit Allowance Increase
Complete your beneficiary designation in Section 4a
 50 Percent Beneficiary Option 3
and 4b
Choose one of the options below:
 Flexible Beneficiary Option 4
Complete your beneficiary designation in Section 4a
Flexible Beneficiary Option 4 Specific Dollar
Amount to Beneficiary $_____________
Complete your beneficiary designation in Section 4a
Flexible Beneficiary Option 4 Specific
Percentage to Beneficiary _____________%
Page 2 of 9
_____________________________________________________ ________________________________________
Name
Social Security Number or CalPERS ID
Section 4a –Individual Lifetime Beneficiary – Ongoing Monthly Benefit
If you chose one of the following options, your beneficiary may only be your spouse/registered domestic partner.
Please also include your spouse/domestic partner’s birth certificate and a copy of your marriage certificate.
Upon your death, your designated beneficiary will receive the ongoing monthly benefit.
100 Percent Beneficiary Option 2 with Benefit Allowance Increase
100 Percent Beneficiary Option 2
50 Percent Beneficiary Option 3 with Benefit Allowance Increase
50 Percent Beneficiary Option 3
Flexible Beneficiary Option 4
_________________________________________________________ _____________________________________
Name (First Name, Middle Initial, Last Name)
Social Security Number
______________________
Male
Female
________________________________________________
Date of Birth (mm/dd/yyyy)
Gender
Relationship to You
_______________________________________________________________________________________________
Address
_______________________________________________________________________________________________
City
State
Zip
Country
Section 4b – Return of Remaining Contributions
If choosing Return of Remaining Contributions Option 1 as your option election, your beneficiary may only be
your spouse/registered domestic partner. This designation automatically revokes when there is a change in your
marital/domestic partnership status.
_________________________________________________________ _____________________________________
Name (First Name, Middle Initial, Last Name)
Social Security Number
_____________________
Male
Female
________________________________________________
Date of Birth (mm/dd/yyyy)
Gender
Relationship to You
_______________________________________________________________________________________________
Address
_______________________________________________________________________________________________
City
State
Zip
Country
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
If you are unmarried or if you chose the following options, your beneficiary for the return of remaining
contributions portion may only be your estate.
100 Percent Beneficiary Option 2
50 Percent Beneficiary Option 3
Page 3 of 9
_____________________________________________________ ________________________________________
Name
Social Security Number or CalPERS ID
Section 5 – Member Signature and Notary
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.
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 change or cancel this application, I must notify the Judges’ Retirement System II within 30 days of the issuance
of my first retirement allowance check.
 I am not married/in a registered domestic partnership
__________________________________________
__________________________________________________________
Date (mm/dd/yyyy)
Spouse/Registered Domestic Partner’s Signature
Date (mm/dd/yyyy)
Member’s Signature
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)
Page 4 of 9
Justification for Non Signature of Spouse or
Registered Domestic Partner
The member’s current spouse/registered domestic partner must be made aware of the selection of
benefits or change of beneficiary made by a member. The spouse/registered domestic partner of a
member must acknowledge the submission of: a request for refund of contributions, election of
retirement optional settlement, and designation for retirement death benefits.
If a spouse/registered domestic partner’s signature does not appear on one of the above named
documents, the following information MUST be completed by the member and submitted with the
application for retirement.
☐ Judges’ Retirement System
☐ Judges’ Retirement System II ☐ Legislators’ Retirement System
________________________________________
__________________________________
Name
Social Security Number or CalPERS ID
I am not legally married or have a registered domestic partnership because:
Never married/or had a registered domestic partner
Divorced/marriage or domestic partnership annulled
_______________________________________
Date
(mm/dd/yyyy)
Widowed
___________________________________________________________________________
Date
(mm/dd/yyyy)
I am legally married or have a registered domestic partner, but my spouse/registered domestic partner did
not sign the form because:
I do not know and have taken all reasonable steps to determine the whereabouts of my
spouse/registered domestic partner,
My spouse/registered domestic partner has been advised of the application and has refused to sign
the acknowledgment,
My spouse/registered domestic partner is incapable of executing the acknowledgment because of an
incapacity mental or physical condition,
My spouse/registered domestic partner has no identifiable community property interest in the benefit,
My spouse/registered domestic partner and I have executed a marriage/partnership settlement
agreement, which
makes the community property law inapplicable to the marriage/partnership.
I hereby certify, under the penalty of perjury, that the foregoing information is true and correct.
_____________________________________________________
____________________________________
Date
Member’s Signature
(mm/dd/yyyy)
Page 5 of 9
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