Form PERS-BSD-369-S "Service Retirement Election Application" - California

This version of the form is not currently in use and is provided for reference only.
Download this version of Form PERS-BSD-369-S for the current year.

What Is Form PERS-BSD-369-S?

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 July 1, 2017;
  • 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 PERS-BSD-369-S 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-369-S "Service Retirement Election Application" - California

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Service Retirement Election Application
888 CalPERS (or 888-225-7377)
TTY: (877) 249-7442
Please do not mail or deliver your application to CalPERS more than 120 days before your retirement date.
For detailed instructions on how to complete this form, please refer to the Service Retirement Election
Application publication (PUB 43).
Information About You
Section 1
Please provide your
Your Name (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
name as it appears on
your Social Security card.
Address
City
State
ZIP
Country
(
)
(
)
c
Male
c
Female
Birth Date (mm/dd/yyyy)
Gender
Daytime Phone
Alternate Phone
Email Address
Information About Your Retirement
Section 2
Please enter the last day
Last Day on Payroll (mm/dd/yyyy)
Your Retirement Date (mm/dd/yyyy)
you were on payroll with a
CalPERS-covered employer.
Employer Full Name
Full Position Title
Temporary Annuity
Choosing to receive a temporary annuity will permanently reduce your retirement benefit. Please refer
to the Temporary Annuity publication (PUB 13) before making this choice.
To elect to receive a temporary annuity payment, select one of the choices below.
In the event of your death,
any outstanding temporary
I became a member prior to January 1, 2002, and elect to receive temporary annuity until
c
annuity payments will be
age
in the amount of $
per month.
paid in a lump sum to a
(59½ or whole age 60 to 68)
Dollars
beneficiary. Complete your
I became a member on or after January 1, 2002, and have CalPERS service coordinated
c
beneficiary information
with Social Security. I elect to receive temporary annuity until age
in the amount
(62 to 70)
in Section 4c.
of $
per month.
Dollars
Other California Public Retirement Systems
If you are a member of a California public retirement system other than CalPERS, please complete the following:
Name of Reciprocal System
Last Day of Employment With Reciprocal System (mm/dd/yyyy)
Retirement Date With Reciprocal System (mm/dd/yyyy)
PERS-BSD-369-S (7/17)
Page 1 of 9
Service Retirement Election Application
888 CalPERS (or 888-225-7377)
TTY: (877) 249-7442
Please do not mail or deliver your application to CalPERS more than 120 days before your retirement date.
For detailed instructions on how to complete this form, please refer to the Service Retirement Election
Application publication (PUB 43).
Information About You
Section 1
Please provide your
Your Name (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
name as it appears on
your Social Security card.
Address
City
State
ZIP
Country
(
)
(
)
c
Male
c
Female
Birth Date (mm/dd/yyyy)
Gender
Daytime Phone
Alternate Phone
Email Address
Information About Your Retirement
Section 2
Please enter the last day
Last Day on Payroll (mm/dd/yyyy)
Your Retirement Date (mm/dd/yyyy)
you were on payroll with a
CalPERS-covered employer.
Employer Full Name
Full Position Title
Temporary Annuity
Choosing to receive a temporary annuity will permanently reduce your retirement benefit. Please refer
to the Temporary Annuity publication (PUB 13) before making this choice.
To elect to receive a temporary annuity payment, select one of the choices below.
In the event of your death,
any outstanding temporary
I became a member prior to January 1, 2002, and elect to receive temporary annuity until
c
annuity payments will be
age
in the amount of $
per month.
paid in a lump sum to a
(59½ or whole age 60 to 68)
Dollars
beneficiary. Complete your
I became a member on or after January 1, 2002, and have CalPERS service coordinated
c
beneficiary information
with Social Security. I elect to receive temporary annuity until age
in the amount
(62 to 70)
in Section 4c.
of $
per month.
Dollars
Other California Public Retirement Systems
If you are a member of a California public retirement system other than CalPERS, please complete the following:
Name of Reciprocal System
Last Day of Employment With Reciprocal System (mm/dd/yyyy)
Retirement Date With Reciprocal System (mm/dd/yyyy)
PERS-BSD-369-S (7/17)
Page 1 of 9
Put your name and Social
Security number or CalPERS ID
Your Name
Social Security Number or CalPERS ID
at the top of every page
Select Your Retirement Payment Option
Section 3
Choose one of the following retirement payment options.
Your retirement payment
Unmodified Allowance
There is no beneficiary designation with this option. Skip to Section 5.
c
option choice becomes
Return of Remaining
Complete your beneficiary designation in Section 4c.
c
irrevocable 30 days
Contributions Option 1
from the date your first
retirement check is issued
100 Percent Beneficiary Option 2
c
Complete your beneficiary designation in Section 4a.
with Benefit Allowance Increase
unless you have a future
qualifying event, such as
100 Percent Beneficiary Option 2
Complete your beneficiary designation in Section 4a and 4c.
c
the death of a beneficiary or
a change in marital status.
50 Percent Beneficiary Option 3
Complete your beneficiary designation in Section 4a.
c
with Benefit Allowance Increase
50 Percent Beneficiary Option 3
c
Complete your beneficiary designation in Section 4a and 4c.
Flexible Beneficiary Option 4
c
Choose one of the options below.
Specific Percentage
Complete your beneficiary designation in Section 4b.
c
Specific Dollar Amount
Complete your beneficiary designation in Section 4b.
c
Court-Ordered Community
Provide your former spouse/partner’s information and choose
c
one of the options below for your share of the benefit.
Property Option 4
If you are required by a
court order to designate
your nonmember spouse
Former Spouse/Former Registered Domestic Partner (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
or partner for an ongoing
monthly benefit, choose
Unmodified Allowance
There is no beneficiary designation with this option. Skip to Section 5.
c
one of the Court-Ordered
Return of Remaining
Community Property
Complete your beneficiary designation in Section 4c.
c
Contributions Option 1
Option 4 options for your
share of the benefit.
Specific Percentage
Complete your beneficiary designation in Section 4b.
c
Specific Dollar Amount
Complete your beneficiary designation in Section 4b.
c
Complete Your Beneficiary Information – Ongoing Monthly Benefit
Section 4a
If you chose one of the following options, name one beneficiary to receive the ongoing monthly benefit
The beneficiary you name
upon your death.
in this section becomes
irrevocable 30 days
100 Percent Beneficiary Option 2 with Benefit Allowance Increase
from the date your first
100 Percent Beneficiary Option 2
retirement check is issued
50 Percent Beneficiary Option 3 with Benefit Allowance Increase
unless you have a future
50 Percent Beneficiary Option 3
qualifying event, such as
the death of a beneficiary or
Name (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
a change in marital status.
Male
Female
c
c
Birth Date (mm/dd/yyyy)
Gender
Relationship to You
Address
City
State
ZIP
Country
PERS-BSD-369-S (7/17)
Page 2 of 9
Put your name and Social
Security number or CalPERS ID
Your Name
Social Security Number or CalPERS ID
at the top of every page
Complete Your Beneficiary Information – Specific Percentage or
Section 4b
Specific Dollar Amount
If you chose one of the following options, name one or more beneficiaries to receive a specific percentage
Any beneficiary you name
or dollar amount of your Unmodified Allowance upon your death.
in this section becomes
irrevocable 30 days
Flexible Beneficiary Option 4/Specific Percentage or Specific Dollar Amount
from the date your first
Court-Ordered Community Property Option 4/Specific Percentage or Specific Dollar Amount
retirement check is issued
unless you have a future
qualifying event, such as
Name (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
the death of a beneficiary or
Male
Female
$
%
c
c
a change in marital status.
Birth Date (mm/dd/yyyy)
Gender
Relationship to You
Dollar Amount
Percent of Benefit
Complete all fields for each
Address
beneficiary and specify the
percentage or dollar
City
State
ZIP
Country
amount. If you name more
than one beneficiary and
you want your beneficiaries
Name (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
to receive an equal share
c
Male
c
Female
$
%
of your benefits, do not
Birth Date (mm/dd/yyyy)
Gender
Relationship to You
Dollar Amount
Percent of Benefit
specify a dollar or
percentage of benefit.
Address
City
State
ZIP
Country
Name (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
c
Male
c
Female
$
%
Birth Date (mm/dd/yyyy)
Gender
Relationship to You
Dollar Amount
Percent of Benefit
Address
City
State
ZIP
Country
If you want to name more
Name (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
than four beneficiaries, call
Male
Female
$
%
c
c
us toll free at 888 CalPERS
Birth Date (mm/dd/yyyy)
Gender
Relationship to You
Dollar Amount
Percent of Benefit
(or 888-225-7377).
Address
City
State
ZIP
Country
PERS-BSD-369-S (7/17)
Page 3 of 9
Put your name and Social
Security number or CalPERS ID
Your Name
Social Security Number or CalPERS ID
at the top of every page
Complete Your Beneficiary Information – Return of Remaining Contributions
Section 4c
If you want to name
If you chose one of the following options, name one or more beneficiaries to receive a return of any
separate beneficiaries
of your remaining member contributions. You can change this beneficiary designation at any time.
for the balance of your
Return of Remaining Contributions Option 1
remaining contributions
100 Percent Beneficiary Option 2
and/or temporary annuity
50 Percent Beneficiary Option 3
balance, call us toll
Temporary Annuity (remaining balance upon your death)
free at 888 CalPERS
Court-Ordered Community Property Option 4/Return of Remaining Contributions Option 1
(or 888-225-7377).
If you name more than
Name (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
one beneficiary and you
%
c
Male
c
Female
c
Primary
c
Secondary
want your beneficiaries to
Birth Date (mm/dd/yyyy)
Gender
Relationship to You
Priority
Percent of Benefit
receive an equal share of
your benefits, do not
Address
specify a percentage
of benefit.
City
State
ZIP
Country
Name (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
Male
Female
Primary
Secondary
%
c
c
c
c
Birth Date (mm/dd/yyyy)
Gender
Relationship to You
Priority
Percent of Benefit
Address
City
State
ZIP
Country
Name (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
Male
Female
Primary
Secondary
%
c
c
c
c
Birth Date (mm/dd/yyyy)
Gender
Relationship to You
Priority
Percent of Benefit
Address
City
State
ZIP
Country
If you want to name more
Name (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
than four beneficiaries, call
us toll free at 888 CalPERS
Male
Female
Primary
Secondary
%
c
c
c
c
Birth Date (mm/dd/yyyy)
Gender
Relationship to You
Priority
Percent of Benefit
(or 888-225-7377).
Address
City
State
ZIP
Country
PERS-BSD-369-S (7/17)
Page 4 of 9
Put your name and Social
Security number or CalPERS ID
Your Name
Social Security Number or CalPERS ID
at the top of every page
Retired Death Benefit – Beneficiary Designation
Section 5
If you name more than
Name one or more beneficiaries to receive the Retired Death Benefit upon your death. The amount payable
one beneficiary and you
is based on your employer's contract with us. You can change this beneficiary designation at any time.
want your beneficiaries to
receive an equal share of
Name (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
your benefits, do not
specify a percentage
Male
Female
Primary
Secondary
%
c
c
c
c
Birth Date (mm/dd/yyyy)
Gender
Relationship to You
Priority
Percent of Benefit
of benefit.
Address
If you were last employed
with another California
City
State
ZIP
Country
public retirement system,
this benefit is not payable.
Name (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
Male
Female
Primary
Secondary
%
c
c
c
c
Birth Date (mm/dd/yyyy)
Gender
Relationship to You
Priority
Percent of Benefit
Address
City
State
ZIP
Country
Name (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
Male
Female
Primary
Secondary
%
c
c
c
c
Birth Date (mm/dd/yyyy)
Gender
Relationship to You
Priority
Percent of Benefit
Address
City
State
ZIP
Country
If you want to name more
Name (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
than four beneficiaries, call
us toll free at 888 CalPERS
Male
Female
Primary
Secondary
%
c
c
c
c
Birth Date (mm/dd/yyyy)
Gender
Relationship to You
Priority
Percent of Benefit
(or 888-225-7377).
Address
City
State
ZIP
Country
PERS-BSD-369-S (7/17)
Page 5 of 9
Page of 10