Form PERS-BSD-369-NM "Nonmember Service Retirement Election Application" - California

What Is Form PERS-BSD-369-NM?

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, 2018;
  • 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-369-NM 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-NM "Nonmember Service Retirement Election Application" - California

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Nonmember 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 publication Nonmember Service
Retirement Election Application (PUB 44).
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
Your Retirement Date (mm/dd/yyyy)
CalPERS Member Information
Complete all fields. We need this information to ensure your benefit is calculated correctly.
Member’s Name (First Name, Middle Initial, Last Name)
Member’s Social Security Number or CalPERS ID
Check the box that applies to you and enter the effective date.
The effective date is
required. This is not the
Dissolution of Marriage
c
date of separation that
Effective Date (mm/dd/yyyy)
was used to divide the
Legal Separation
c
Effective Date (mm/dd/yyyy)
CalPERS benefits.
Termination of Domestic Partnership
c
Effective Date (mm/dd/yyyy)
Please submit a copy of your Notice of Judgment of Dissolution, Legal Separation, or Termination of
Domestic Partnership with your application.
PERS-BSD-369-NM (12/18)
Page 1 of 8
Nonmember 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 publication Nonmember Service
Retirement Election Application (PUB 44).
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
Your Retirement Date (mm/dd/yyyy)
CalPERS Member Information
Complete all fields. We need this information to ensure your benefit is calculated correctly.
Member’s Name (First Name, Middle Initial, Last Name)
Member’s Social Security Number or CalPERS ID
Check the box that applies to you and enter the effective date.
The effective date is
required. This is not the
Dissolution of Marriage
c
date of separation that
Effective Date (mm/dd/yyyy)
was used to divide the
Legal Separation
c
Effective Date (mm/dd/yyyy)
CalPERS benefits.
Termination of Domestic Partnership
c
Effective Date (mm/dd/yyyy)
Please submit a copy of your Notice of Judgment of Dissolution, Legal Separation, or Termination of
Domestic Partnership with your application.
PERS-BSD-369-NM (12/18)
Page 1 of 8
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 Sections 4a and 4c.
unless you have a future
100 Percent Beneficiary Option 2
c
Complete your beneficiary designation in Section 4a.
qualifying event, such as
with Benefit Allowance Increase
the death of a beneficiary.
50 Percent Beneficiary Option 3
Complete your beneficiary designation in Sections 4a and 4c.
c
50 Percent Beneficiary Option 3
Complete your beneficiary designation in Section 4a.
c
with Benefit Allowance Increase
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
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
from the date your first
100 Percent Beneficiary Option 2 with Benefit Allowance Increase
retirement check is issued
50 Percent Beneficiary Option 3
unless you have a future
50 Percent Beneficiary Option 3 with Benefit Allowance Increase
qualifying event, such as the
death of a beneficiary.
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
Address
City
State
ZIP
Country
PERS-BSD-369-NM (12/18)
Page 2 of 8
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
Any beneficiary you name
in this section becomes
If you chose the following option, name one or more beneficiaries to receive a specific percentage
irrevocable 30 days
or dollar amount of your Unmodified Allowance upon your death.
from the date your first
Flexible Beneficiary Option 4
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.
c
Male
c
Female
$
%
Birth Date (mm/dd/yyyy)
Gender
Relationship to You
Dollar Amount
Percent of Benefit
Complete all fields for each
beneficiary and specify the
Address
percentage or dollar
amount. If you name more
City
State
ZIP
Country
than one beneficiary and
you want your beneficiaries
to receive an equal share
Name (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
of your benefits, do not
c
Male
c
Female
$
%
specify a dollar or
Birth Date (mm/dd/yyyy)
Gender
Relationship to You
Dollar Amount
Percent of Benefit
percentage of benefit.
Address
City
State
ZIP
Country
Name (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
Male
Female
$
%
c
c
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
$
%
us toll free at 888 CalPERS
c
c
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-NM (12/18)
Page 3 of 8
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 name more than
If you chose one of the following options, name one or more beneficiaries to receive a return of any
one beneficiary and you
of your remaining member contributions. You can change this beneficiary designation at any time.
want your beneficiaries to
Return of Remaining Contributions Option 1
receive an equal share of
100 Percent Beneficiary Option 2
your benefits, do not
50 Percent Beneficiary Option 3
specify a percentage
of benefit.
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
Name (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
c
Male
c
Female
c
Primary
c
Secondary
%
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
c
Male
c
Female
c
Primary
c
Secondary
%
us toll free at 888 CalPERS
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-NM (12/18)
Page 4 of 8
Put your name and Social
Security number or CalPERS ID
Your Name
Social Security Number or CalPERS ID
at the top of every page
Prorated Allowance Beneficiary Designation
Section 5
All applicants must
This section designates the person or persons you wish to receive an equal share of your lump-sum pro rata benefit.
complete this section.
Name (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
If you name more than one
c
Male
c
Female
c
Primary
c
Secondary
%
beneficiary and you want
Birth Date (mm/dd/yyyy)
Gender
Relationship to You
Priority
Percent of Benefit
your beneficiaries
to receive an equal share
Address
of your benefits, do not
specify a percentage
City
State
ZIP
Country
of benefit.
Name (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
c
Male
c
Female
c
Primary
c
Secondary
%
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-NM (12/18)
Page 5 of 8
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