Fillable Printable Application for Service or Disability Retirement -Maryland

Application for Service or Disability Retirement -Maryland

MARYLAND STATE RETIREMENT AGENCY

120 EAST BALTIMORE STREET

BALTIMORE, MARYLAND 21202-6700

APPLICATION FOR SERVICE OR DISABILITY RETIREMENT

IMPORTANT: If you are applying for disability, this form must be completed

and filed within 120 days of notification of Board approval for disability

retirement. COMAR 17.04.03.16E states, if a State employee is approved for

disability retirement by the Maryland State Retirement Agency, unless the

employee resigns or is removed earlier, the employee shall be considered

resigned from State service as of the 120

day after the approval.

FOR RETIREMENT USE ONLY FORM 13-23 (REV. 4/15)

INSTRUCTIONS FOR COMPLETION OF APPLICATION

IMPORTANT: Read the following instructions and information carefully before filling out this form.

NEED HELP: If you need help to complete this form, or need information on your retirement benefits or retirement process, call

a retirement benefits specialist at 410-625-5555 or 1-800-492-5909.

1. Under the non-contributory pension system, benefit payments cannot be paid for periods prior to the date you file this

application, so file at least two weeks before your selected effective date.

2. In addition to this form, you are required to complete Forms 127 (Reemployment After Retirement), 85 (Direct Deposit -

Electronic Funds Transfer Sign-Up) and 766 (Federal and Maryland State Tax Withholding Request) and forward them to

your Retirement Coordinator.

3. If you have chosen payment Option 2, 3, 5 or 6, you must verify your beneficiary's date of birth by attaching a copy of his or

her birth certificate, valid driver=s license or other proof of birth. You can name only one beneficiary under these options.

For information on other acceptable proofs of birth date, call a retirement benefits specialist at the number shown above.

4. If you are electing Option 2 or 5, you cannot designate a beneficiary who is more than 10 years younger unless the

beneficiary is your spouse or disabled child. If you elect Option 2 or Option 5 and designate your disabled child, you must

submit a completed Form 143 with this application.

5. If you wish to purchase previous service or apply for military service for which you are eligible, ask your Retirement

Coordinator for the proper form(s) and submit it with this application. Additional credit cannot be claimed or purchased

after your retirement.

6. If you wish to name more than one beneficiary and you are choosing the Option 1 Allowance or the Option 4 Allowance,

you should not fill out the ADesignation of Beneficiary@ section on page 2. Instead, fill out and attach Form 4 (Designation

of Beneficiary Form).

7. If you are eligible to participate in the State Employees Health Insurance Program, only Option 2, 3, 5 or 6 continue health

program coverage for your eligible surviving dependents after your death. Contact your employing agency for details.

8. You may change your retirement allowance selection only by filing a change with the Maryland State Retirement Agency

before your first payment normally becomes due. In most cases, the first payment is due 30 days after the effective date of

your retirement. For example, if your effective retirement date is July 1 and you elected Option 5, you have until July 30 to

change your option selection with the State Retirement Agency. You may not change your option selection after monthly

benefit payments have commenced.

9. If you die before the effective date of your retirement, your beneficiary cannot receive a retirement allowance even if you

have completed this form. If you are still in active service at the time of your death, your beneficiary is only eligible for the

active service death benefit.

10. You may change your beneficiary at any time. Depending on the option you have chosen, however, your retirement

allowance may have to be recalculated to reflect the change. Your benefit amount could be reduced as a result of the

change. For more information, call a retirement benefits specialist.

11. You must retire within 30 days of separating from employment with a participating employer to receive additional creditable

service for your unused sick leave. Unused sick leave is sick leave that was available to an employee as sick leave during

employment and was not used before retirement. Any converted leave that was not sick leave during employment may not

be reported.

12. Generally speaking, a member may not receive more than one type of retirement benefit.

13. If you have voluntary contributions in your account and have elected to withdraw them in a lump sum, you must attach

completed Form 742 (Application for Withdrawal of Voluntary Funds), Form 193 (Trustee-to-Trustee Distribution Form) if

applicable and Form 746 (Acknowledgement of Receipt of Safe Harbor Notice and Affirmative Election) to this application.

These forms may be obtained by calling a retirement benefits specialist at the number shown above.

14. Refer to Form 127 (Reemployment After Retirement), which should be submitted with this application, for an explanation of

how post retirement employment may affect your retirement benefits.

Page 1 of 6

Month Day Year

APPLYING FOR : Service Retirement

Check only one box Ordinary Disability Retirement

Accidental Disability Retirement

APPLICATION FOR SERVICE OR DISABILITY RETIREMENT

APPLICANT'S SOCIAL SECURITY NUMBER Gender

(M or F)

APPLICANT=S NAME

First Initial Last

HOME ADDRESS

Number and Street

City State ZIP Code

Home telephone - -

I do wish to have my home address released to an Yes

approved public employees’ organization. If left

unchecked, my address will not be released.

Have you applied to purchase all additional credit Yes

for which you are eligible and intend to purchase? No

Have you applied for credit for your active duty Yes

military service? No

Home email address: ___________________________________________

I request that my

retirement allowance

be effective on

Are you a U.S. citizen? Yes No

I have Voluntary Monies: (see instructions on page one)

I want my voluntary funds refunded in a one-time distribution.

I want my voluntary funds to remain as a monthly additional annuity.

DESIGNATION OF BENEFICIARY: If more than one beneficiary will be designated by members who select either the Basic

Allowance, the Option 1 allowance, or the Option 4 allowance complete the A Designation of Beneficiary@ Form 4 instead of the

following section. Effective January 1, 2006, retirees electing Option 2 or 5 cannot designate a beneficiary who is more than 10

years younger unless the beneficiary is the retiree=s spouse or disabled child.

Check here to indicate that Form 4 is attached.

BENEFICIARY'S SOCIAL SECURITY NUMBER Gender DATE OF BIRTH

¯ ¯

RELATIONSHIP*_____________________

¯ ¯

(M or F) Month Day Year

*If spouse, please indicate state/jurisdiction where marriage license was issued: ________________ Date of Marriage: ________

BENEFICIARY=S NAME

First Initial Last

BENEFICIARY’S ADDRESS

Number and Street

City State Zip Code

I hereby authorize the Board of Trustees to make payment according to the retirement allowance option selected on page three (3) to the

beneficiary whom I have designated and agree on behalf of myself and my heirs and assigns, that payment so made shall be a complete

discharge of the claim and shall constitute a release of the System from any further obligation on account of the benefit. I hereby direct that

should the beneficiary of the above-named benefit die before me, the amount which otherwise would have been payable to such beneficiary

shall become a part of and be paid to my estate, or to such other beneficiary as I shall hereafter designate by written designation filed with the

State Retirement Agency in accordance with the rules and regulations prescribed by the Board of Trustees.

Complete Signature ___________________________________________________ Date Signed _______________________________

This form must be signed and notarized in order to be valid.

¯ ¯

State of __________________ County of __________________ (or City of Baltimore)

On this ________ day of _________________, 20 _________, before me, the undersigned

officer, personally appeared _____________________________________________________, known to me

NAME OF PERSON WHOSE SIGNATURE IS BEING ACKNOWLEDGED *

(or satisfactorily proven) to be the person whose name is subscribed to the within instrument and acknowledged that

(he/she) executed the same for the purposes therein contained. In witness whereof I hereunto set my hand and official seal.

Signature of Notary Public ________________________________

Printed Name of Notary Public _____________________________ My Commission Expires ___________

* IMPORTANT: If the name of the individual whose si

nature is bein

acknowled

ed is not filled in

this form will be INVALID and have no le

al effect.

Official

Seal must

be affixed

Page 2 of 6

RETIREMENT ALLOWANCE OPTIONS

YOU MAY CHOOSE ONLY ONE OF THE FOLLOWING OPTIONS.

INDICATE YOUR SELECTION BY SIGNING IN THE APPROPRIATE BOX BELOW.

BASIC ALLOWANCE:

The Basic Allowance pays you the largest possible amount of money each month until your death. All monthly

payments stop at your death, including beneficiary health coverage for state employees. After your death, your

beneficiary or estate will receive one payment if your death occurs on the 16

of the month or later.

SIGNATURE DATE

OPTION 1:

Provides a lower monthly benefit than the Basic Allowance, but guarantees monthly payments that equal the total of

your retirement benefit=s Present Value. The Present Value of your benefit is figured at the time of your retirement. If

you die before receiving monthly payments that add up to the Present Value, the remaining payments will be paid in a

lump sum to your designated beneficiary or beneficiaries who remain alive. For state employees: Option 1 does not

provide for continued beneficiary health coverage after your death.

SIGNATURE DATE

OPTION 2:

Provides a lower monthly benefit than the Basic Allowance, but guarantees that after your death the same monthly

benefit will continue to be paid to your surviving beneficiary for his or her lifetime. No further payments will be made

after the deaths of you and your beneficiary. If you choose this option, you must send proof of your beneficiary=s date

of birth with this application. Retirees electing Option 2 cannot designate a beneficiary who is more than 10 years

younger unless the beneficiary is the retiree=s spouse or disabled child.

SIGNATURE DATE

OPTION 3:

Provides a lower monthly benefit than the Basic Allowance, but guarantees that after your death one half of the

monthly benefit paid to you will be paid to your surviving beneficiary for his or her lifetime. No further payments will be

made after the deaths of you and your beneficiary. If you choose this option, you must send proof of your beneficiary=s

date of birth with this application.

SIGNATURE DATE

OPTION 4:

Provides a lower monthly benefit than the Basic Allowance, but Guarantees the return of your accumulated

contributions and interest as established when you retire. If you die before you have recovered the full amount of your

accumulated contributions and interest, the remainder will be paid in a lump sum to your designated beneficiary or

beneficiaries who remain alive. For state employees: Option 4 does not provide for continued beneficiary health

coverage after your death.

SIGNATURE DATE

OPTION 5:

Provides a lower monthly benefit than the Basic Allowance, but guarantees that after your death the same monthly

benefit paid to you will be paid to your surviving beneficiary for his or her lifetime. It also provides that your monthly

benefit will Apop-up@ to the Basic Allowance for your lifetime the month following the death of your beneficiary if your

beneficiary dies before you. If your original beneficiary dies and you are collecting the Basic Allowance and decide to

name a new beneficiary, your benefit will be recalculated under Option 5 based on the new beneficiary designation.

If you choose this option, you must send proof of your beneficiary=s date of birth with this application. Retirees electing

Option 5 cannot designate a beneficiary who is more than 10 years younger unless the beneficiary is the retiree=s

spouse or disabled child.

SIGNATURE DATE

OPTION 6:

Provides a lower monthly benefit than the Basic Allowance, but guarantees that after your death one half of the

monthly benefit paid to you will be paid to your surviving beneficiary for his or her lifetime. It also provides that your

monthly benefit will Apop-up@ to the Basic Allowance for your lifetime the month following the death of your beneficiary

if your beneficiary dies before you. If your original beneficiary dies and you are collecting the Basic Allowance and

decide to name a new beneficiary, your benefit will be recalculated under Option 6 based on the new beneficiary

designation. If you choose this option, you must send proof of your beneficiary=s date of birth with this application.

SIGNATURE DATE

Page 3 of 6

APPLICATION FOR SERVICE OR DISABILITY RETIREMENT

To be completed by employer and returned with application

Employer’s Certification of Separation from Employment, Wages, Contributions and Sick Leave

For:

Applicant’s Name Job Classification

Applicant’s Social Security number:

A. The most recent payroll period reported was:

Month Day Year

B. The projected payroll information to be reported prior to retirement is:

Contribution $ _____________ Standard hours _________ Actual Hours Paid _________ Pay Period Ending ___________________

MO DAY YR

Contribution $_____________ Standard hours _________ Actual Hours Paid _________ Pay Period Ending ___________________

MO DAY YR

Contribution $_____________ Standard hours _________ Actual Hours Paid _________ Pay Period Ending ___________________

MO DAY YR

Final

Contribution $____________ Standard Hours _________ Actual Hours Paid _________ Pay Period Ending ___________________

MO DAY YR

No retirement contribution is due for a pay period ending on or after the retirement date.

C. The employee is separating from employment with the employer. The employee=s last day on payroll is: __ .

Federal law prohibits the Maryland State Retirement and Pension System from paying benefits prior to "separation from

employment." "Separation from employment" may only occur on resignation, retirement, discharge, or death, and not on

transfer, promotion, or otherwise continuing employment with the same employer without interruption. Effective July 1, 2005,

State law requires that there be a minimum of 45 days between the last day on payroll, as set forth above, and the date the

employee is rehired by (a) a unit of state government if the employee's current employer is a unit of state government, or (b)

a participating employer if the employee's current employer is the same participating employer.

D. Salary Change: Did the employee=s salary change since most recent payroll period reported or will

the employee’s salary change before the date of retirement?.....................................................................( ) YES ( ) NO

If yes, the employee=s new annual salary is $ and is effective

MO DAY YR

E. Unused Sick Leave: Member must retire within 30 days of separating from employment to be eligible to receive

additional creditable service for unused sick leave. The agency must be notified of all changes in unused sick leave. Unused

sick leave must be reported at the time the member files for retirement and again 30 days after the effective date of

retirement. Retirement Coordinator: Please retain a copy and submit recertified sick leave 30 days after retirement. Unused

sick leave is sick leave that was available to an employee as sick leave during employment and was not used before

retirement. Any converted leave that was not sick leave during employment may not be reported.

Initial

Reporting:

Total DAYS of unused sick leave (If none, enter word NONE) as of

MO DAY YR

Recertified

Sick

Leave:

Total DAYS of unused sick leave (If no change, enter no change) as of

MO DAY YR

Retirement Coordinator recertif

leave must initial here:

I certify that the above information regarding wages, contributions, separation from service, and sick leave is true and accurate

to the best of my knowledge and that I am authorized to certify this information by the employer. I will report any changes to

unused sick leave occurring between the date certified and the actual date of retirement.

_________________________________ _______________________________ _________________________________

Signature of Authorized Agent Printed Name of Authorized Agent Title of Authorized Agent

_________________________________ _______________________________ _________________________________

Date Full Name of Employer DIRECT Telephone Number

Submit form directly to: Maryland State Retirement and Pension System, 120 East Baltimore St., Baltimore, MD 21202-6700

Page 4 of 6

Apply to purchase any eligible service credit that is not in your account by completing the Request to

Purchase Previous Service (Form 26) in the 12 months before you retire. You must submit your request to

purchase service prior to retiring. A purchase of service increases the amount of service in your account

towards becoming eligible to retire as well as the amount of your retirement benefit.

Claim your military service by completing the Claim of Retirement Credit for Military Service (Form 43)

and submitting it to SRA before you retire. You must have at least 10 years of creditable state service in

order to claim military service that occurred prior to your membership. Claiming military service increases

the amount of service in your account towards becoming eligible to retire as well as the amount of your

retirement benefit.

Submit a request for an estimate by filing the Application for an Estimate of Service Retirement Allowance

(Form 9) within 12 months of retiring. See the Important Points to Know sheet that accompanies Form 9

for more information.

Determine when you want to retire. Go to your Retirement Coordinator, usually someone in your person-

nel or payroll office, and ask for the retirement forms to retire. You should receive the following forms:

Application for Service or Disability Retirement Form (Form 13-23)

Direct Deposit Electronic Fund Transfer Sign-Up (Form 85)

Federal and State Tax Withholding Request (Form 766)

Reemployment After Retirement (Form 127)

Retirement forms should be sent to the Retirement Agency four to eight weeks before you retire. Form 13-

23 can only be sent to the Agency from your employer so please allow sufficient time for your employer to

process information on the back of the form and send it to the Agency.

Ask any questions you have on retirement issues or forms to SRA retirement benefits specialists. You can

make an appointment to see a specialist or you can talk with a specialist by calling 410-625-5555 or toll-

free 1-800-492-5909.

Read carefully the first page of Form 13-23. Be sure you understand all information on the front page

before completing the form. If you need any help, contact a retirement benefits specialist at 410-625-5555

or toll free at 1-800-492-5909.

Any unused sick leave days that you have at retirement may be converted into months to add to

your monthly benefit provided you retire within 30 days of separating from employment.

Please review the following information when planning and filing for retirement.

For retirement counseling call: 410-625-5555 or 1-800-492-5909.

Important Points To Know...

when filing the

Application for Service or Disability Retirement (Form 13-23)

The Maryland State Retirement and Pension System

120 East Baltimore Street · Baltimore, MD 21202-6700

sra.maryland.gov

Continued on following page.

Page 5 of 6

For State employees and employees of the University System of Maryland: If you are eligible to partici-

pate in the State Employees' Health Insurance Program, only selection of Option 2, 3, 5, or 6 will allow

your eligible surviving dependents to continue health program coverage after your death. You must

choose either Option 2, 3, 5, or 6 and name your spouse as beneficiary in order for the spouse to contin-

ue health insurance after your death.

Choose a retirement date. If you choose the first of a month as your retirement date, you will receive your

monthly retirement benefit at the end of that month. If you choose a date other than the first of the month,

your first retirement benefit will be paid the end of the following month and it will be for one month's

income only. You must be separated from employment on the date that you enter as your retirement date.

If you have voluntary money, decide how you want that money paid to you. To verify if you have any vol-

untary money, refer to your most recent Personal Statement of Benefits or call a retirement benefits spe-

cialist at 410-625-5555 or toll-free 1-800-492-5909.

Name your beneficiary (ies). If you have selected Option 2, 3, 5, or 6, you may only name one beneficiary.

If you choose the Basic Allowance, Option 1 or Option 4, you may name multiple beneficiaries. If you are

naming multiple beneficiaries, check the box on Form 13-23 that indicates you are submitting Form 4 with

your beneficiary information. Do not enter one beneficiary on Form 13-23 and the rest on Form 4. Enter

multiple beneficiaries on Form 4.

Choose your payment option. Be sure you understand each option before making your choice. Your esti-

mate should be helpful in choosing the option best suited to you and to those who may rely upon you for

continuing income after your death. Contact a retirement benefits specialist if you have questions regarding

the payment options. You may not change your payment option once your first payment comes due.

Submit proof of birth of your beneficiary if you choose Option 2, 3, 5, or 6. You may submit a copy of an

unexpired driver's license, MD identification card provided by the Motor Vehicle Administration, birth cer-

tificate, passport, or military documentation, as examples.

If you have chosen Option 2 or Option 5 and your beneficiary is your disabled child, you must have a

physician complete the Verification of Retiree’s Disabled Child for Selection of Option 2 / 5 Beneficiary

(Form 143) and attach it to this application.

No offers of reemployment should be made or discussed by you and your current employer until after

you have retired. Maryland law requires you to wait at least 45 days from your date of retirement before being

reemployed as a retiree by your same employer. In this instance, all state agencies including the University

System of Maryland are considered the same employer. If you return to work for the same employer, you may

be subject to an earnings limitation as well as IRS rules may apply. Refer to the information on the most current

Reemployment After Retirement (Form 127) for an explanation of the reemployment rules. If you have any

questions, contact a retirement benefits specialist at 410-625-5555 or toll-free at 1-800-492-5909.

Again, to receive credit for any unused sick leave days you have at retirement, you must retire within 30

days from when you separated from employment. Unused sick leave is sick leave that was available to an

employee as sick leave during employment and was not used before retirement. Any converted leave that

was not sick leave during employment may not be reported.

Important Points to Know when filing the Application for Service or

Disability Retirement (Form 13-23)

Continued from previous page.

Page 6 of 6