Application for Service or Disability Retirement -Maryland

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 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.
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.
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