Retirement Application Supporting Documents Please contact Human Resources with any questions pertaining to Health Insurance. Please provide the following when applying for retirement: Application for Service Retirement: Your completed Application for Service Retirement can be submitted to the Retirement Office no earlier than 60 days before or no later than, the day of your retirement. Benefit Payment Option: The Benefit Payment Option form showing your option election signed by the member and the spouse or registered domestic partner, if applicable. Death Benefit Designation: Death Benefit Beneficiary Designation form naming a primary beneficiary Retiree and Beneficiary age verification: Certified copy of your birth certificate or your passport* Certified copy of the birth certificate or passport of your spouse/domestic partner* Certified copy of the birth certificate or passport of any person you will name as a beneficiary to receive a continuance upon your death* Registered Marriage Certificate or California Certificate of Domestic Partnership: Certified copy of Marriage Certificate or California Certificate of Domestic Partnership, to determine eligibility for the unmodified option* Social Security number(s) of your named beneficiary (ies) Return to Work Acknowledgement: Acknowledgement of laws governing working retirees Direct Deposit Authorization: Please complete and submit with a void blank check for checking account deposit, or a savings institution verification of complete account number and signatory name for a savings account direct deposit. Tax Withholding Election: Federal withholding section: All retirees State withholding section: California residents only * Staff will make a photocopy and return the original document to you. 1
Application for Service Retirement To the Board of Retirement County of Mendocino Ukiah, California Date In accordance with the provisions of the County Employees Retirement Law Act of 1937 and the By-Laws and Regulations governing the Retirement System, I, hereby make application for retirement from service. Print Member Name Title or Position Social Security Number Department I request that my retirement become effective on the day of, 20 I was born on. (Month/Day/Year) My mailing address is Telephone ( ) Email My street address* is *If mailing address is a P.O. Box your street address is required. I nominate my as my beneficiary whose date of birth is (Relationship) (Month/Day/Year) Print Name of Beneficiary Social Security Number My Beneficiary s address is _ Telephone ( ) Email Date of Marriage or Registered Domestic Partnership (if applicable) (Month/Day/Year) Signature of Member Date 2
Benefit Payment Options and Election Because your option choice is irrevocable, it is important to consider your selection carefully. The following retirement benefit options determine the form and extent of benefits distributed during your retirement and upon your death. You may want to consult with a Retirement Specialist before you make your selection. Please contact the retirement office with your questions or to schedule an appointment. Print Member Name Date of Retirement Unmodified Allowance Member Initials Spouse or RDP Initials In general, the unmodified allowance provides for the highest possible monthly retirement benefit during your life. This option provides, upon your death, a lifetime benefit equal to 60% of the benefit you received during retirement to your eligible beneficiary (60% benefit + 60% cost of living). This survivor benefit is restricted to your eligible spouse, qualified domestic partner or eligible child only. Your spouse or qualified domestic partner are considered eligible if you have been married for at least one year at the time of your retirement and you are married to that spouse at the time of your death. If you do not have an eligible spouse or qualified domestic partner, the 60% benefit may be paid to your eligible child upon your death. An eligible child is an unmarried child under the age of 18, or an unmarried full-time student under the age of 22. If you do not have an eligible spouse, qualified domestic partner or eligible child at the time of your death, your designated beneficiary will receive a lump-sum refund of any of your remaining contributions and interest. Under the Unmodified Option, you may change your designated beneficiary for the death benefit at any time without affect to the 60% benefit payable to an eligible spouse, qualified domestic partner or eligible child. Option 1 Member Initials Spouse or RDP Initials This option provides a lesser monthly allowance and no continuance. Upon your death, a lump-sum payment of any remaining contributions becomes payable to your named beneficiary. Each month the annuity portion of your benefit is deducted from your contributions until the balance of your contributions is zero. You will continue to receive your benefit, but there would no longer be a lump-sum benefit payable to your beneficiary. You may change your named beneficiary for Option 1 at any time. 3
Benefit Payment Options and Election, Continued Option 2 Member Initials Spouse or RDP Initials At the time of your death, your designated beneficiary will receive the same monthly allowance you were receiving at the time of your death for the remainder of his or her lifetime (100% benefit + 100% cost of living). An Actuary calculation may be required if the named beneficiary is not your spouse and/or they are more than 10 years younger than you. In order to provide this continuance, your benefit is reduced during your retirement based on your life expectancy and the life expectancy of your beneficiary. Should your beneficiary pre-decease you, you will continue to receive the same reduced amount and you will not be allowed to designate a new beneficiary. Age 62 Modified Allowance Member Initials Spouse or RDP Initials This option provides for a larger benefit from the age you retire to age 62, based upon your Social Security estimate of benefits receivable at age 62. A Personal Earnings Statement from the Social Security Administration, showing zero future earnings and a retirement benefit amount, is required to process this option. A sample statement may be obtained from our office prior to your visit to the SSA. At age 62, your benefit will be reduced by the Social Security estimate amount you provided at the time of your retirement. This option can give you a more level payment for your life consisting of a combination of your Social Security benefit and Mendocino CERA retirement. I understand that my option choice is irrevocable and cannot be changed once I have received my first benefit payment. I/We elect the following Option: Print Member Name Member Signature Date The signature of the spouse or registered domestic partner must be notarized unless signed in the presence of a member of the Mendocino CERA staff, with proof of identification. Print Spouse/Domestic Partner Name Spouse/Domestic Partner Signature Retirement Representative Signature Date Date 4
Burial Benefit Beneficiary Designation Member First Name (Print) Member Last Name (Print) Middle Initial Date of Birth Social Security Number Home/Mailing Address City State Zip Code Email Daytime Phone Number ( ) A $1,000.00 burial benefit shall be paid upon the death of any member after retirement and while receiving a monthly retirement allowance pursuant to Government Code Sections 31789 and 31789.13. This burial benefit shall be payable only to retirees who rendered his/her last service with Mendocino County, the Mendocino County Superior Court, or the Russian River Cemetery District and shall be paid to a beneficiary nominated by the member by written designation. Please name the beneficiary/beneficiaries you wish to receive this benefit below. If you elect an Estate or Trust, please attached the estate or trust documentation, including the name and contact information of the executor/executors or trustee/trustees. Please remember to keep your beneficiary information up to date. Primary (Print) Name Relationship % of Benefit Date of Birth Social Security or Tax ID Home/Mailing Address Daytime Phone Number ( ) City State Zip Code Primary or Contingent (Optional) Name Relationship % of Benefit Date of Birth Social Security or Tax ID Home/Mailing Address Daytime Phone Number ( ) City State Zip Code Primary or Contingent (Optional) Name Relationship % of Benefit Date of Birth Social Security or Tax ID Home/Mailing Address Daytime Phone Number ( ) City State Zip Code I hereby confirm the beneficiary designations shown above. Member Signature Date 5
Return to Work Acknowledgement Government Code 7522.56 restricts a public employer s ability to reemploy a retired person, a person who (1) previously retired under the employer s pension plan, and (2) is currently receiving a benefit from that plan. A retired person shall not serve, be employed by, or be employed through a contract directly by, a public employer in the same public retirement system from which the retiree receives the benefit without reinstatement in the employer s plan upon reemployment. This means that the retired person s benefit payments under the plan would be suspended, and his or her compensation during the reemployment period would be pensionable. The retired person would receive service credit under the pension plan for the reemployment period, and the employer and retired person would have to pay required contributions to fund the corresponding benefits. The law, however, provides that reinstatement is not required if the following conditions are satisfied: The employer s appointing power reemploys the retired person either during an emergency to prevent stoppage of public business, or because the retired person has skills needed to perform work of limited duration; The retired person s appointment is for no more than 960 hours per fiscal year; The retired person s pay rate must be within the range paid by the employer to other employees performing comparable duties (pay rate for this purpose is hourly and is determined by dividing monthly pay by 173.33, which may not make economic sense depending on the circumstances); The retired person must certify in writing to the employer that he or she did not, during the 12- month period preceding the reemployment date, receive unemployment insurance arising from prior employment with the reemploying employer or any other employer that maintains the same pension plan; and The retired person cannot be reemployed within 180 days after his or her previous employment terminated, with limited exceptions for critically needed positions, safety officers, and certain other situations. If these conditions are satisfied, reinstatement does not apply. The retired person would continue to receive retirement benefits under the employer s plan, would not receive service credit for the reemployment period and no plan contributions on the retired person s compensation would be required. I acknowledge that I have read and understand the above. Member Signature Date 6
Tax Withholding Election Name Social Security Number Mailing Address City/State Zip Code Street Address City/State Zip Code *If mailing address is a P.O. Box your street address is required. Federal Tax Withholding Certificate for Pension or Annuity Payments (W-4P) Make only one election, sign and return: Do not withhold Federal Income Tax. Withhold Federal Income Tax based on the tax tables for: CAUTION: There are penalties for not paying enough taxes during the year. Estimated tax requirements and penalties are explained in IRS Publication 505. Married, with tax withholding allowances. (enter a number from 0 to 10) Single, or Married (with two or more incomes), with tax withholding allowances. (enter a number from 0 to 10) In addition to the amount withheld based on the tax tables, withhold $.00 monthly. State of California (EDD) Tax Withholding Certificate for Pension or Annuity Payments (DE-4P) Make only one election, sign and return: Do not withhold State of California Income Tax. Withhold this designated amount of State of California Income Tax. I want $.00 withheld monthly. Withhold State of California Income Tax based on the tax tables for: Married, with tax withholding allowances. (enter a number from 0 to 10) Single, or Married (with two or more incomes), with tax withholding allowances. (enter a number from 0 to 10) Head of Household, with tax withholding allowances. (enter a number from 0 to 10) In addition to the amount withheld based on the tax tables, withhold $.00 monthly. Signature Phone Number Date Email Address 7
This combination Federal Tax Withholding Certificate (W-4P) and State of California Tax Withholding Certificate (DE-4P) is being provided for you to make your tax withholding elections. This form may be used for both federal and state tax withholding. Please make one election for each and be sure to sign the certificate before returning it to MCERA. Federal Tax Withholding Information Federal regulations require all payees whose allowances are taxable to either make a specific election for no withholding or make an election using the tax tables based on marital status and exemption allowances. If no election is filed, MCERA is required by law to withhold taxes based on tax tables for married with three exemptions. Taxes will not be withheld unless your gross benefit exceeds the minimum amount listed on the tax table for that filing status. IRS Code requires MCERA to automatically withhold federal income tax at the married and claiming three tax withholding allowances rate from: Individuals who provide a PO Box as their home address and US citizens and resident aliens who are living outside of the United States. To have MCERA withhold federal tax at a rate other than married with three allowances or to elect not to have tax withheld, use this form to submit a US home address with a street number. (In the event of an IRS audit, it will be your responsibility to substantiate your residence.) This rule applies to federal income tax only. We are required to remind you that there are penalties imposed by the IRS for not paying enough taxes during the year. Established tax requirements and penalties are explained in IRS Publication 505. Additionally, Publication 575, Pension and Annuity Income may also be of assistance. State of California Tax Withholding Information Unless you elect otherwise, the law requires that personal income tax be withheld, using the marital status and withholding allowance claimed on your W-4P. In compliance with Federal law, California income tax is not to be withheld from pension recipients who reside outside of California. If you prefer to use the Federal and State issued withholding forms, please see your tax advisor or contact us at (707) 463-4328. Service Connected Disabilities IF YOU HAVE PREVIOUSLY FILED A TAX WITHHOLDING ELECTION FORM, THE CALIFORNIA WITHHOLDING ELECTION WILL REMAIN IN EFFECT UNTIL A NEW WITHHOLDING CERTIFICATE IS FILED. If you were granted a Service Connected Disability, withholding tax will be based solely on the taxable portion (if any) of your retirement allowance. If your allowance is equal to 50 percent of your final compensation at retirement, your allowance qualifies as fully non-taxable. If your allowance exceeds 50 percent of your final compensation at retirement, the portion of your allowance over 50 percent is taxable. NOTE: Failure to properly complete the withholding form will result in MCERA rejecting your form. Return completed form to: MCERA, 625-B Kings Court, Ukiah, CA 95482 or fax (707) 467-6472. 8
Direct Deposit Authorization I hereby authorize the (MCERA) to deposit all pension/annuity payments due to me from MCERA directly into the account identified below. This authority will remain in effect until I notify MCERA in writing to terminate this authorization. I understand that I must give MCERA enough notice to allow reasonable time to act on my instructions. In the event an overpayment from MCERA is credited to my account during or after my lifetime, I authorize MCERA to direct my financial institution to refund the same to MCERA and charge such payment to my account. I understand that I will not receive a check stub with automatic deposit, but can request this information by contacting MCERA. Print Member Name Member Signature Social Security Number Date Financial Institution Information: Please attach a voided blank check to your account HERE. Deposit slips cannot be accepted. (OR) If you would like to request deposit to a savings account, please attach typed confirmation of your savings account number and routing number from your financial institution. 9
Association of Mendocino County Retired Employees (AMCRE) Membership Application and Authorization AMCRE Association of Mendocino County Retired Employees APPICATION FOR MEMBERSHIP AND AUTHORIZATION FOR AUTOMATIC DEDUCTION By signing and submitting this form with retirement papers, I agree to become an AMCRE member and authorize the dues to be paid by automatic deduction from my monthly benefit. PLEASE MARK EITHER THE REGULAR MEMBERSHIP BOX OR BOTH REGULAR MEMBERSHIP AND ASSOCIATE MEMBERSHIP BOXES. Regular Membership Retiree: $1.00 per month Associate Membership Beneficiary:.66 cents per month PLEASE PRINT THE INFORMATION BELOW. Name: Phone: Mailing Address: Street P.O.Box City: State: Zip Code: Email Address: Date Retired: Department: Years of Service: Email [ ] or Mail [ ] the AMCRE newsletter-the Connection- to me. Signature: Date: Authorization for Automatic Deduction of AMCRE Dues I hereby authorize the Retirement Association to deduct the amount of $ per month from my monthly retirement benefits for payment of membership dues to The Association of Mendocino County Retired Employees (AMCRE). I understand that this authorization will be in effect until revoked by myself, my surviving spouse and/or beneficiary, or another person that I have designated in writing to do so. Print Name Signature Date 10
Frequently Asked Questions Congratulations on your decision to retire. It is our hope that we can assist you in making your transition an easy and pleasant experience. We have prepared this information to answer many of your questions prior to your date of retirement. If you have questions or concerns that are not addressed, please contact the retirement office at (707) 463-4328 or contact us online at www.co.mendocino.ca.us/retirement. Some of the most commonly asked questions are as follows: Q. How much will my retirement benefit be? A. Retirement benefit estimates may be requested by completing and submitting an Estimate of Retirement Benefit Request form to the retirement office. This form is available at http://www.co.mendocino.ca.us/retirement/. This estimate will be based on the service and salary information readily available at that time. This is only an estimate. The final calculation will be done after your requested retirement date and will be based on your final compensation and the number of sick leave hours you have in reserve. (Sick leave hours count toward your retirement service time at 100 %.) Q. When will I get my first retirement check? A. Retirement benefit payments are processed once a month and paid on the last banking day of each month. If you retire on the 1 st of the month you should receive your first benefit payment at the end of that month. If you retire on the 2nd of the month or thereafter you should receive your first benefit payment on the last banking day of the following month which will include a pro-rated amount for the day in the month of retirement Q. How do I sign up for direct deposit? A. You can sign up for direct deposit at any time. You will need to complete an authorization form and submit it to the retirement office with a voided check attached. This form is available at http://www.co.mendocino.ca.us/retirement/. The direct deposit will take 2 months to start. The first month you will receive your benefit payment by check which will be mailed to you. This allows time for us to prenote your bank account with a zero deposit. The second month you will receive your benefit payment by direct deposit. When your direct deposit begins you will no longer receive a check stub stating your benefit and deductions. You may request this information from the retirement office at any time. Q. Can I access my retirement account information online? A. Yes. MemberDirect is a new site where Active and Retired members can view their account information securely online. Visit the MCERA website at http://www.co.mendocino.ca.us/retirement/ for Retirement Association information, Board of Retirement meeting information, and forms and access to MemberDirect at https://mceraprod.pensiongoldhosting.com/wmswebsite/login.aspx?returnurl=%2fwmswebsite. Informational guides are provided on the MCERA website with information on how to enroll in MemberDirect and use the site. If you do not have access to a computer the retirement office is always available to assist members personally. Office hours are Monday through Thursday 9:00am to Noon and 1:00 pm to 4:00pm, and Friday 9:00 am to Noon. 11
Q. Explain the Annual Cost of Living increase. A. Your retirement benefit includes an Annual Cost of Living (COLA) increase of 0 to 3% effective each April 1. This increase is based on the December Consumer Price Index (CPI) for the San Francisco- Oakland-San Jose Area rounded to the nearest one-half percent and is approved by the Board of Retirement. Q. How do I get information about COBRA insurance? Is dental and vision insurance coverage available? A. You may contact a Human Resources Benefits Specialist at (707) 234-6600 for COBRA Benefit information. Dental and vision plans are available to Association of Mendocino County Retired Employees (AMCRE) members. Please call the Pacific Group Agencies at (800) 511-9065 for enrollment and/or dental and vision insurance questions. Q. What about income taxes? A. The retirement office is not allowed to make decisions regarding your taxable income and will not calculate your tax withholding. If you want to have taxes withheld from your monthly retirement benefit you will need to complete a tax withholding form and submit it to the retirement office. If you need assistance in calculating your state and federal taxes you should consult with a tax specialist. You may make changes to your tax withholding at any time. This form is also available at http://www.co.mendocino.ca.us/retirement/. Q. In the event of my death what will happen to my retirement benefit? A. At the time of your retirement you will be asked to choose a benefit option and to designate a beneficiary. Benefit options will be discussed with you at the time of your retirement. Once an option is chosen it is irrevocable and cannot be changed after you have retired. At the time of your death, if your last period of service was with MCERA, your designated beneficiary will receive a $1,000.00 death benefit. Be sure your beneficiary designation is always up-to-date. Q. Will my retirement benefits end when my contributions are exhausted? A. No. Your retirement benefit will continue for your lifetime, and depending on the benefit option chosen, your surviving spouse or domestic partner (of at least one year prior to retirement) will receive a benefit for the remainder of their life. A designated beneficiary who is a minor child will receive a continuation until age 21 if enrolled in an accredited school and unmarried. We hope that this information helps you with your retirement planning. Please let the retirement office know if you need more information or if you need to schedule an appointment to meet with a retirement specialist. 12