Informational Sheet- Application for Pension

Transcription

1 33 Plaza La Prensa, Santa Fe, NM (505) Fax (505) Vice (800) Tll-Free Infrmatinal Sheet- Applicatin fr Pensin If yu are cnsidering retiring, PERA requests that yu submit the fllwing dcuments t us at least sixty (60) Calendar days in advance f yur anticipated retirement date. Please nte that PERA cannt prcess yur retirement benefits withut receiving all f the cmpleted dcuments. If we d nt receive all cmpleted frms yur retirement date will be pstpned until all dcumentatin is received. Required Frms fr a Cmplete Applicatin fr Pensin (Please nte PERA must receive all riginal frms that require a ntary stamp.) Please prvide curt endrsed cpies f yur divrce decree and prperty settlement agreement(s) that happened while a PERA member. If the divrce happened prir t PERA Membership and yu have nt remarried, prvide a cpy f nly the divrce decree. If yu remarried prir t PERA membership and are still married t the same persn, yu d n need t prvide any divrce dcumentatin. When is yur Retirement effective? Yur Retirement becmes effective the First Day f the Mnth Fllwing: Applicatin fr Pensin Frm PERA Tax Deductin Frm PERA Spusal Cnsent Frm PERA Affirmatin f Marital Status frm (if nt married at the time f retirement) Cpy f a birth r baptismal certificate fr yurself and yur Beneficiary Cpy f yur marriage Certificate (if applicable) PERA Direct Depsit Frm Cpy f a Scial Security Card fr yu and yur Beneficiary Receipt f yur cmpleted Applicatin fr Pensin packet Terminatin f yur emplyment with yur current PERA emplyer Determinatin by PERA that yu have successfully met all eligibility requirements and cnditins fr retirement When are yur benefits paid? PERA retirement benefits are paid nce a mnth n the last wrking day f each mnth. Yur benefit payments will be electrnically transferred n the last wrking day f each mnth t the financial institutin selected n yur PERA Direct Depsit Authrizatin Frm. Direct depsit f benefit payments is mandatry. If yu wish t change yur retirement day yu must cmplete a PERA Change in Retirement Date Frm prir t yur effective retirement date (Frm can be fund n ur website Failure t d s may result in a delay f yur benefit payment. Be sure t include yur scial security number r PERA ID number, yur telephne number and yur current address n all crrespndence. Beneficiary Selectin If yu chse Frm f Payment A: Please name a refund beneficiary r rganizatin. Upn yur death, if the ttal amunt f payments received is less than yur ttal emplyee cntributins, the difference will be refunded t yur refund beneficiary r the rganizatin specified. If n refund beneficiary designatin is n recrd, any emplyee cntributins will be refunded t yur estate. If yu chse Frm f Payment B, C, r D: please give us the full name, address, date f birth and relatinship. If yu are married n the date f yur retirement and d nt name yur spuse as survivr beneficiary, yur spuse must cnsent in writing. Yu must submit prf f age n yurself and yur survivr beneficiary as well as marriage certificates r divrce decrees and prperty settlement agreements. If Frm f Payment D is desired, yu must prvide prf f age n each child under the age f 25. IMPORTANT! If yu chse yur spuse as yur beneficiary and yur spuse dies, yur pensin will be changed t Frm f Payment A fllwing the receipt f yur spuse's death certificate. Yu have a ne-time irrevcable ptin t name a new beneficiary. In the event f divrce pst-retirement, PERA can revert the retiree t Frm f Payment A fllwing the receipt f the applicable curt rder. Retirees wh name a beneficiary ther than their spuse at the time f retirement have a ne-time irrevcable ptin t change their beneficiary under the same frm f payment r mve up t Frm f Payment A. Please cntact PERA if yu need additinal infrmatin abut any f these ptins.

2 33 Plaza La Prensa, Santa Fe, New Mexic (505) fax (505) vice (800) Tll-Free APPLICATION FOR PENSION FORM Instructins: Please print r type in a dark ink, and cmplete all sectins cntained n the frm GENERAL INFORMATION PLEASE TYPE OR PRINT CLEARLY SOCIAL SECURITY NUMBER r PERA ID NUMBER NAME FIRST MI LAST MAILING ADDRESS CITY STATE ZIP MARITAL STATUS NEVER MARRIED MARRIED DIVORCED WIDOWED HAVE YOU BEEN DIVORCED? Yes N If yes, please prvide curt endrsed cpies f yur divrce decree and prperty settlement agreement(s) as stated in the infrmatinal sheet. Check t receive crrespndence Yes N DO YOU HAVE SERVICE CREDIT IN ANY OF THESE PLANS? PERA ERB MRA JRA Legislative LAST PERA AFFILIATED EMPLOYER PLANNED TERMINATION DATE Date yu leave/left emplyment EFFECTIVE RETIREMENT DATE The first day f a mnth DATE OF BIRTH BENEFICIARY DESIGNATION AND FORM OF PAYMENT Upn retirement, yu may select ONE f the fllwing frms f payment f a pensin. PERA will prvide yu with an estimate f yur benefits as requested belw. Please visit fr additinal infrmatin related t payment ptin selectin. Frm f Payment A: Straight Life Optin. Prvides a benefit t yu fr yur lifetime. Payments stp upn yur death. Frm f Payment B: Jint Survivr Optin (100%). Prvides a benefit t yu fr yur lifetime with the same amunt cntinuing fr life t yur beneficiary upn yur death. Frm f Payment C: Jint Survivr Optin (50%). Prvides a benefit t yu fr yur lifetime with 50% f that amunt cntinuing fr life t yur beneficiary upn yur death. Frm f Payment D: Temprary Jint Survivr Optin (Children). Prvides a benefit t yu fr life, with the same amunt cntinuing t yur eligible children until each child reaches age 25. Prvide beneficiary infrmatin fr each child. Magistrate - Judicial: Survivr pensin paid accrding t each specific statute. FORM OF PAYMENT A ONLY ORGANIZATION AS A REFUND BENEFICIARY Organizatin Name Address/Phne Number Organizatin Tax ID Number PERSON AS A REFUND OR SURVIVOR BENEFICIARY FORM OF PAYMENT A, B, C & D. Fr Frm f Payment D, prvide beneficiary infrmatin fr each child. Name FIRST MI LAST Relatinship Mailing Address City State Zip Beneficiary s Scial Security Number Date f Birth APPLICANT'S STATEMENT I am hereby applying fr retirement benefits as indicated abve. I understand my retirement benefits will begin n the first f the mnth fllwing the cmpletin f all the fllwing: 1) meeting the age and service requirements fr nrmal retirement; 2) the cmpletin f all retirement kit frms; and 3) Terminatin f all emplyment frm a PERA and ERB affiliated emplyer(s). I als understand that if I shuld ever return t wrk fr any PERA affiliated emplyer, I must cntact PERA and my pensin may be subject t suspensin. I certify that the infrmatin cntained herein is true and crrect t the best f my knwledge. APPLICANT'S SIGNATURE HOME OR CELL NUMBER DATE ( ) Octber 2016

3 33 Plaza La Prensa, Santa Fe, New Mexic (505) fax (505) vice (800) Tll-Free AFFIRMATION OF MARITAL STATUS FORM This frm affirms t PERA yu are nt currently married. If yu are married at the time f retirement, cmplete a Spusal Cnsent Frm. Instructins: Please print r type in dark ink. The riginal f this frm must be cmpleted in its entirety and returned t PERA fr prcessing. Required fields are in BOLD ITALICS. N crrectin fluid will be allwed n this frm. GENERAL INFORMATION PLEASE TYPE OR PRINT CLEARLY SOCIAL SECURITY NUMBER r PERA ID NUMBER FIRST NAME MI LAST NAME MAILING ADDRESS CITY STATE ZIP HOME r CELL TELEPHONE NO. DATE OF BIRTH MARITAL STATUS NEVER MARRIED MARRIED DIVORCED WIDOWED HAVE YOU BEEN DIVORCED? Yes N If yes, please prvide curt endrsed cpies f yur divrce decree and prperty settlement agreement(s) that happened while a PERA member. If the divrce happened prir t PERA membership and yu have nt remarried, prvide a cpy f nly the divrce decree. If yu remarried prir t PERA membership and are still married t the same persn, yu d nt need t prvide any divrce dcumentatin. I,, an applicant fr PERA pensin benefits, affirm that I am nt currently legally married. This des nt include a legal separatin. DATE SIGNATURE OF RETIREE in the presence f a ntary PERA Rule B(3)NMAC requires that the retiring member prvides PERA with curt endrsed cpies f all divrce rders and marital settlement agreements entered after the first PERA membership applicatin is filed, if the member has been previusly married. T ensure that the member receives a pensin fr the retirement date chsen, the cmpleted retirement applicatin shuld be returned t PERA with all required dcuments at least 60 days prir t retirement. The cmpleted applicatin and supprting dcumentatin must be filed with PERA n later than the clse f business n the last wrking day f the mnth prir t the selected date f retirement in accrdance A(1)NMAC. NOTARIZATION OF RETIREE S SIGNATURE Retiree s Signature Must be Dne In The Presence Of A Ntary State f New Mexic ) ) SS: Cunty f ) Signed and swrn t (r affirmed) befre me by n this the day f,. My Cmmissin Expires Ntary Public Telephne N - - Ntary Signature N crrectin fluid will be allwed n this frm. September 2015

4 SPOUSAL CONSENT FORM 33 Plaza La Prensa, Santa Fe, New Mexic (505) fax (505) vice (800) Tll-Free Instructins: Please print r type in dark ink. The riginal f this frm must be cmpleted in its entirety and returned t PERA fr prcessing. Required Fields are in BOLD ITALICS. Additinal instructins are n the back. N crrectin fluid will be allwed n this frm. SPOUSE S INFORMATION AND NOTARIZATION In The Presence Of A Ntary I,, spuse f (Spuse s Name) (please print) cnsent t his/her decisin t receive (Retiree s Name) (please print) benefits under Frm f Payment with named as survivr beneficiary. (Beneficiary s Name) (please print) I understand that I will nt be entitled t survivr benefits unless I have been listed n the Final Applicatin fr Annuity as the beneficiary under either Frm f Payment B r C. Date State f New Mexic ) ) SS: Cunty f ) Signature f Retiree s Spuse Signed and swrn t (r affirmed) befre me by n this the day f (Spuse s Name) (please print),. My Cmmissin Expires Ntary Public Telephne N - - NOTARIZATION OF RETIREE S SIGNATURE In The Presence Of A Ntary Signature f Retiree Retiree Name (please print) State f New Mexic ) ) SS: Cunty f ) Ntary Signature Retiree s Scial Security Number r PERA ID Number Date Signed and swrn t (r affirmed) befre me by n this the day f (Retiree s Name) (please print),. My Cmmissin Expires Ntary Public Telephne N - - Ntary Signature Instructins n back PERA Rule B (3)NMAC requires that the retiring member prvides PERA with curt endrsed cpies f all divrce rders and marital settlement agreements entered after the first PERA membership applicatin is filed. The member shuld return the cmpleted Applicatin fr Pensin with all required dcumentatin t PERA at least sixty (60) calendar days prir t the selected date f retirement. If the member des nt specify a frm f payment prir t their retirement date, the retirement applicatin will be prcessed accrding t NMSA 1978, Sectin A(1)(2004). This sectin f the state statute requires payment t be made under Frm f Payment A if there is n eligible spuse r under Frm f Payment C if there is an eligible spuse. If payments are t be made under Frm f Payment C accrding t this sectin, the eligible spuse will be designated as the survivr beneficiary. N crrectin fluid will be allwed n this frm. September 2015

5 INSTRUCTIONS FOR COMPLETING THE SPOUSAL CONSENT FORM N crrectin fluid will be allwed n this frm. Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Step 7 Step 8 Step 9 The retiree s spuse must cmplete, date and sign this dcument in the Spuse s Infrmatin and Ntarizatin sectin in frnt f a ntary public. Yur spuse prints his/her name in the first space designated spuse s name. Yur spuse prints yur name in the secnd space designated retiree s name. Yur spuse prints the Frm f Payment ptin that has been agreed upn in the third space after Frm f Payment. Yur spuse prints the name f the agreed upn beneficiary in the space designated beneficiary s name, even if yur spuse is the beneficiary. This blank must be filled in even if selecting Frm f Payment A. If yu desire t name n ne as a beneficiary, PERA will accept language such as n ne r n/a. If n beneficiary is named, member cntributin balances will be paid t the retiree s estate upn death. Yur spuse must sign and date this dcument in frnt f a ntary public. The fllwing must be filled in by the ntary public: The ntary public must write dwn in which cunty they are signing the dcument. The ntary must print yur spuse s name in the space designated spuse s name. The ntary must fill ut the cmplete date. The ntary must fill in his/her term expiratin date. The ntary must either imprint r stamp this dcument. The ntary must sign his/her name in the space designated Ntary Signature. The retiree must sign and date this dcument in the Ntarizatin f Retiree s Signature sectin in frnt f a ntary public. The fllwing must be filled in by the ntary public: The ntary public must write dwn in which cunty they are signing the dcument. The ntary must print the retiree s name in the space designated retiree s name. The ntary must fill ut the cmplete date. The ntary must fill in his/her term expiratin date. The ntary must either imprint r stamp this dcument. The ntary must sign his/her name in the space designated Ntary Signature.

6 33 Plaza La Prensa, Santa Fe, New Mexic (505) fax (505) vice (800) Tll-Free *DDF* PERA DIRECT DEPOSIT AUTHORIZATION FORM Please select ne: New Frm Change In Existing Infrmatin Please select ne: Member I Receive a Benefit as a Beneficiary PERA ID r SSN: FIRST NAME MI LAST NAME MAILING ADDRESS - Check bx fr Address Change HOME r CELL TELEPHONE NO. CITY STATE ZIP Yu are hereby directed t electrnically transfer my mnthly benefit check t the: Name f Financial Institutin: Accunt Number: Type f Accunt: Checking Savings I authrize PERA t make credit and debit entries t my accunt at the abve named financial institutin. I agree t ntify PERA immediately upn discvery f any errrs resulting frm transactins under this authrizatin and f any changes that may affect these instructins. I agree t hld PERA and the State f New Mexic harmless frm any and all lss, cst, damage, r expenses suffered as a result f errrs in credit r debit entries caused by persns nt emplyed by PERA. I direct the abve named financial institutin t refund t PERA any depsits made t my accunt after my death in accrdance with the agreement set frth belw. Yur Signature: Date: Financial Institutin Use Only: THIS MUST BE COMPLETED BEFORE BEING SUBMITTED TO PERA Agreement f Depsitry Financial Institutin In accrdance with the authrizatin f the depsitr, we hereby agree t credit and debit t depsitr's accunt, benefit payments and crrectins made by the New Mexic Public Emplyees Retirement Assciatin withut depsitr's endrsement. We further agree t repay and refund t PERA n demand, the ttal amunt f any such payments received and depsited t the accunt f the depsitr, the due date f which ccurs subsequent t the death f the depsitr, and agree t accept the certificatin f PERA as sufficient evidence f the date f death f the depsitr. By signature heren we have verified the accunt number f the depsitr. Financial Institutin Ruting Number: Cnfirmatin f Custmer's Accunt Number: Name f Financial Institutin: Address: City: State: Zip: Authrized Signature: Date: YOU MUST ATTACH A VOIDED CHECK HERE OR A COMPLETED DIRECT DEPOSIT FORM FROM YOUR BANK (Please d nt include a cpy f a depsit slip) March 2017

7 33 Plaza La Prensa, Santa Fe, New Mexic (505) fax (505) vice (800) Tll-Free *TDF* PERA TAX DEDUCTION FORM Instructins: This frm must be cmpleted in its entirety and returned t PERA fr prcessing. Additinal instructins are n the back page. Check One: New Change In Existing Infrmatin MEMBER INFORMATION PRINT CLEARLY PERA ID r SSN: FIRST NAME MI LAST NAME MAILING ADDRESS HOME r CELL TELEPHONE NO. CITY STATE ZIP CHECK ONLY THE APPLICABLE BOXES AUTHORIZATION I submit this PERA Tax Deductin Frm specifying what deductins I authrize t be made frm my PERA retirement benefit fr Federal and New Mexic State Incme Tax purpses. SIGNED DATE March 2017

8 NMRHCA Medical Plan Mnthly Premium Cntributins fr January 1, December 31,2018 (applicable if retirement date is after June 30, 2001)

9 Medical Plan Rate Calculatin Instructins 1. Select a medical plan fr the retiree; enter the rate frm the Retiree Rate rw that crrespnds with yur years f service. 2. If yu are enrlling yur spuse r dmestic partner, select a medical plan fr him/her; enter the rate frm the Spuse Rate rw that crrespnds with yur years f service (r, if yur spuse/dmestic partner is als an NMRHCA-eligible retiree, use the Retiree Rate that crrespnds with yur spuse s/dmestic partner s years f service). 3. If yu are als enrlling children, enter rate frm Child Rate rw multiplied by number f children. (# f Children: x Child Rate: = Ttal fr Child(ren): $ Retiree + $ Spuse/ Dmestic Partner + $ Child(ren) 4. TOTAL #1, #2, and #3. Vluntary Cverage Premiums DENTAL PLAN Mnthly Premium*: Effective January 1, 2017 t December 31, 2017 = $ Ttal SINGLE TWO-PARTY FAMILY Delta Dental Basic $18.51 $34.72 fr bth $ fr all Delta Dental Cmprehensive $41.32 $78.52 fr bth $ fr all United Cncrdia Basic $16.80 $31.91 fr bth $ fr all United Cncrdia Cmprehensive $34.28 $65.12 fr bth $ fr all VISION PLAN Mnthly Premium*: Effective January 1, 2017 t June 30, 2017 Davis Visin $ 4.76 $ 8.98 fr bth $13.23 fr all DEPENDENT CHILD LIFE Mnthly Premium*: Effective January 1, 2016 t December 31, 2017 The Standard Insurance $2,500 - $3.83 fr all $5,000 - $7.15 fr all $10,000 - $13.83 fr all RETIREE/SPOUSE SUPPLEMENTAL LIFE Mnthly Premium*: Effective January 1, 2016 t December 31, 2017 The Standard $2,000 $4,000 $6,000 $8,000 $10,000 $15,000** $20,000** $40,000** $46,000** $60,000** Age $ 0.68 $ 0.86 $ 1.05 $ 1.23 $ 1.41 $ 1.87 $ 2.32 $ 4.14 $ 4.69 $ 5.96 Age $ 0.79 $ 1.08 $ 1.38 $ 1.67 $ 1.96 $ 2.69 $ 3.42 $ 6.34 $ 7.22 $ 9.26 Age $ 1.03 $ 1.56 $ 2.08 $ 2.61 $ 3.14 $ 4.46 $ 5.78 $ $ $ Age $ 1.36 $ 2.22 $ 3.07 $ 3.93 $ 4.79 $ 6.94 $ 9.08 $ $ $ Age $ 1.92 $ 3.34 $ 4.77 $ 6.19 $ 7.61 $11.17 $14.72 $ $ $ Age $ 2.23 $ 3.96 $ 5.70 $ 7.43 $ 9.16 $13.49 $17.82 $ $ $ Age $ 4.05 $ 7.61 $11.16 $14.72 $18.27 $27.16 $36.04 $ $ $ Age 70 and ver $ 5.95 $11.40 $16.85 $22.30 $27.75 $41.38 $55.00 $ $ $ *This is ptinal cverage, and the entire cst f cverage is paid by yu. Cst f insurance fr all cverages paid by yu may increase r decrease in the future based upn the claims experience f participants. All prvisins that apply t this cverage are gverned by the Certificate. The life plan rates include a $.50 administratin fee. **Evidence f Insurability Statement required t add r increase life insurance. The frm can be fund at