Application for Service or Disability Retirement -Maryland
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.
OR
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
g
nature is bein
g
acknowled
g
ed is not filled in
,
this form will be INVALID and have no le
g
al effect.
Official
Seal must
be affixed
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