33 Plaza La Prensa, Santa Fe, NM 87507 (505) 476-9401 Fax (505)476-9300 Voice

(800) 342-3422 Toll-Free www.nmpera.org

Informational Sheet- Application for Pension

If you are considering retiring, PERA requests that you submit the following documents to us at least sixty (60) Calendar days in advance of your anticipated retirement date. Please note that PERA cannot process your retirement benefits without receiving all of the completed documents. If we do not receive all completed forms your retirement date will be postponed until all documentation is received.

• Required Forms for a Complete Application for Pension (Please note PERA must receive all original forms that require a notary stamp.)

o Please provide court endorsed copies of your divorce decree and property settlement agreement(s) that happened while a PERA member. If the divorce happened prior to PERA Membership and you have not remarried, provide a copy of only the divorce decree. If you remarried prior to PERA membership and are still married to the same person, you do no need to provide any divorce documentation.

o Application for Pension Form o PERA Tax Deduction Form o PERA Spousal Consent Form o PERA Affirmation of Marital Status form (if not

married at the time of retirement) o Copy of a birth or baptismal certificate for

yourself and your Beneficiary o Copy of your marriage Certificate (if

applicable) o PERA Direct Deposit Form o Copy of a Social Security Card for you and

your Beneficiary

• When is your Retirement effective? Your Retirement becomes effective the First Day of the Month Following:

o Receipt of your completed Application for Pension packet o Termination of your employment with your current PERA employer o Determination by PERA that you have successfully met all eligibility requirements and

conditions for retirement • When are your benefits paid?

o PERA retirement benefits are paid once a month on the last working day of each month. Your benefit payments will be electronically transferred on the last working day of each month to the financial institution selected on your PERA Direct Deposit Authorization Form. Direct deposit of benefit payments is mandatory.

o If you wish to change your retirement day you must complete a PERA Change in Retirement Date Form prior to your effective retirement date (Form can be found on our website www.nmpera.org). Failure to do so may result in a delay of your benefit payment. Be sure to include your social security number or PERA ID number, your telephone number and your current address on all correspondence.

• Beneficiary Selection o If you chose Form of Payment A: Please name a refund beneficiary or organization. Upon your death, if

the total amount of payments received is less than your total employee contributions, the difference will be refunded to your refund beneficiary or the organization specified. If no refund beneficiary designation is on record, any employee contributions will be refunded to your estate.

o If you chose Form of Payment B, C, or D: please give us the full name, address, date of birth and relationship. If you are married on the date of your retirement and do not name your spouse as survivor beneficiary, your spouse must consent in writing. You must submit proof of age on yourself and your survivor beneficiary as well as marriage certificates or divorce decrees and property settlement agreements. If Form of Payment D is desired, you must provide proof of age on each child under the age of 25.

IMPORTANT! If you choose your spouse as your beneficiary and your spouse dies , your pension will be changed to

Form of Payment A following the receipt of your spouse's death certificate. You have a one-time irrevocable option to name a new beneficiary. In the event of divorce post-retirement, PERA can revert the retiree to Form of Payment A following the receipt of the applicable court order.

Retirees who name a beneficiary other than their spouse at the time of retirement have a one-time irrevocable option to change their beneficiary under the same form of payment or move up to Form of Payment A. Please contact PERA if you need additional information about any of these options.

33 Plaza La Prensa, Santa Fe, New Mexico 87507 (505) 476-9401 fax (505) 476-9300 voice

(800) 342-3422 Toll-Free www.nmpera.org

APPLICATION FOR PENSION FORM Instructions: Please print or type in a dark ink, and complete all sections contained on the form

GENERAL INFORMATION – PLEASE TYPE OR PRINT CLEARLY SOCIAL SECURITY NUMBER or PERA ID NUMBER NAME FIRST MI LAST

MAILING ADDRESS CITY STATE ZIP

MARITAL STATUS NEVER MARRIED MARRIED DIVORCED WIDOWED

HAVE YOU BEEN DIVORCED? Yes No If yes, please provide court endorsed copies of your divorce decree and property settlement agreement(s) as stated in the informational sheet.

Check to receive e-mail correspondence Yes No E-Mail:

DO YOU HAVE SERVICE CREDIT IN ANY OF THESE PLANS? PERA ERB MRA JRA Legislative

LAST PERA AFFILIATED EMPLOYER DATE OF BIRTH

PLANNED TERMINATION DATE Date you leave/left employment

EFFECTIVE RETIREMENT DATE The first day of a month

BENEFICIARY DESIGNATION AND FORM OF PAYMENT Upon retirement, you may select ONE of the following forms of payment of a pension. PERA will provide you with an estimate of your benefits as requested below. Please visit www.nmpera.org for additional information related to payment option selection.

Form of Payment A: Straight Life Option. Provides a benefit to you for your lifetime. Payments stop upon your death.

Form of Payment B: Joint Survivor Option (100%). Provides a benefit to you for your lifetime with the same amount continuing for life to your beneficiary upon your death. Form of Payment C: Joint Survivor Option (50%). Provides a benefit to you for your lifetime with 50% of that amount continuing for life to your beneficiary upon your death. Form of Payment D: Temporary Joint Survivor Option (Children). Provides a benefit to you for life, with the same amount continuing to your eligible children until each child reaches age 25. Provide beneficiary information for each child.

Magistrate - Judicial: Survivor pension paid according to each specific statute.

FORM OF PAYMENT A ONLY – ORGANIZATION AS A REFUND BENEFICIARY

Organization Name Address/Phone Number Organization Tax ID Number

PERSON AS A REFUND OR SURVIVOR BENEFICIARY – FORM OF PAYMENT A, B, C & D. For Form of Payment D, provide beneficiary information for each child.

Name FIRST MI LAST Relationship

Mailing Address City State Zip

Beneficiary’s Social Security Number Date of Birth

APPLICANT'S STATEMENT I am hereby applying for retirement benefits as indicated above. I understand my retirement benefits will begin on the first of the month following the completion of all the following: 1) meeting the age and service requirements for normal retirement; 2) the completion of all retirement kit forms; and 3) Termination of all employment from a PERA and ERB affiliated employer(s). I also understand that if I should ever return to work for any PERA affiliated employer, I must contact PERA and my pension may be subject to suspension. I certify that the information contained herein is true and correct to the best of my knowledge. APPLICANT'S SIGNATURE HOME OR CELL NUMBER

( ) DATE

October 2016

I, ______________________________________ , an applicant for PERA pension benefits, affirm that I am not currently legally married. This does not include a legal separation.

______________________ ________________________________________ DATE SIGNATURE OF RETIREE – in the presence of a notary

PERA Rule 2.80.700.10.B(3)NMAC requires that the retiring member provides PERA with court endorsed copies of all divorce orders and marital settlement agreements entered after the first PERA membership application is filed, if the member has been previously married.

To ensure that the member receives a pension for the retirement date chosen, the completed retirement application should be returned to PERA with all required documents at least 60 days prior to retirement. The completed application and supporting documentation must be filed with PERA no later than the close of business on the last working day of the month prior to the selected date of retirement in accordance 2.80.700.10.A(1)NMAC.

33 Plaza La Prensa, Santa Fe, New Mexico 87507 (505) 476-9401 fax (505) 476-9300 voice

(800) 342-3422 Toll-Free www.nmpera.org

AFFIRMATION OF MARITAL STATUS FORM

This form affirms to PERA you are not currently married. If you are married at the time of retirement, complete a Spousal Consent Form.

Instructions: Please print or type in dark ink. The original of this form must be completed in its entirety and returned to PERA for processing. Required fields are in BOLD ITALICS.

No correction fluid will be allowed on this form.

GENERAL INFORMATION – PLEASE TYPE OR PRINT CLEARLY

SOCIAL SECURITY NUMBER or PERA ID NUMBER

FIRST NAME MI LAST NAME

MAILING ADDRESS CITY STATE ZIP

HOME or CELL TELEPHONE NO.

DATE OF BIRTH MARITAL STATUS NEVER MARRIED MARRIED DIVORCED WIDOWED

HAVE YOU BEEN DIVORCED? Yes No If yes, please provide court endorsed copies of your divorce decree and

property settlement agreement(s) that happened while a PERA member. If the divorce happened prior to PERA membership and you have not remarried, provide a copy of only the divorce decree. If you remarried prior to PERA membership and are still married to the same person, you do not need to provide any divorce documentation.

NOTARIZATION OF RETIREE’S SIGNATURE – Retiree’s Signature Must be Done In The Presence Of A Notary

State of New Mexico )

) SS:

County of ___________________ )

Signed and sworn to (or affirmed) before me by ________________________________ on this the _________ day of

_________________, _______.

My Commission Expires _____________________________

Notary Public Telephone No ______-______-_________ Notary Signature ___________________________________

No correction fluid will be allowed on this form. September 2015

33 Plaza La Prensa, Santa Fe, New Mexico 87507

(505) 476-9401 fax (505) 476-9300 voice (800) 342-3422 Toll-Free

www.nmpera.org

SPOUSAL CONSENT FORM

Instructions: Please print or type in dark ink. The original of this form must be completed in its entirety and returned to PERA for

processing. Required Fields are in BOLD ITALICS. Additional instructions are on the back.

No correction fluid will be allowed on this form.

SPOUSE’S INFORMATION AND NOTARIZATION – In The Presence Of A Notary

I, _______________________________________________________ , spouse of

(Spouse’s Name) (please print)

_________________________________________________________ consent to his/her decision to receive

(Retiree’s Name) (please print)

benefits under Form of Payment ________ with __________________________________ named as survivor beneficiary.

(Beneficiary’s Name) (please print)

I understand that I will not be entitled to survivor benefits unless I have been listed on the Final Application for Annuity as the beneficiary under either Form of Payment B or C.

______________________________ ___________________________________________

Date Signature of Retiree’s Spouse

State of New Mexico )

) SS:

County of ___________________ )

Signed and sworn to (or affirmed) before me by ______________________________________ on this the ________day of

(Spouse’s Name) (please print)

________________, _______.

My Commission Expires ___________________________

Notary Public Telephone No ______-______-_________ Notary Signature __________________________________

NOTARIZATION OF RETIREE’S SIGNATURE – In The Presence Of A Notary

____________________________________________ _____________________________________________

Signature of Retiree Retiree’s Social Security Number or PERA ID Number

____________________________________________ _____________________________________________

Retiree Name (please print) Date

State of New Mexico )

) SS:

County of ___________________ )

Signed and sworn to (or affirmed) before me by _____________________________________ on this the _______ day of

(Retiree’s Name) (please print)

______________________, _______.

My Commission Expires ___________________________

Notary Public Telephone No ______-______-_________ Notary Signature __________________________________

Instructions on back PERA Rule 2.80.700.10.B (3)NMAC requires that the retiring member provides PERA with court endorsed copies of all divorce orders and marital settlement agreements entered after the first PERA membership application is filed. The member should return the completed Application for Pension with all required documentation to PERA at least sixty (60) calendar days prior to the selected date of retirement. If the member does not specify a form of payment prior to their retirement date, the retirement application will be processed according to NMSA 1978, Section 10-11-116 A(1)(2004). This section of the state statute requires payment to be made under Form of Payment A if there is no eligible spouse or under Form of Payment C if there is an eligible spouse. If payments are to be made under Form of Payment C according to this section, the eligible spouse will be designated as the survivor beneficiary.

No correction fluid will be allowed on this form. September 2015

INSTRUCTIONS FOR COMPLETING THE

SPOUSAL CONSENT FORM

No correction fluid will be allowed on this form.

Step 1 The retiree’s spouse must complete, date and sign this document in the Spouse’s Information and Notarization section in front of a notary public.

Step 2 Your spouse prints his/her name in the first space designated “spouse’s name.”

Step 3 Your spouse prints your name in the second space designated “retiree’s name.”

Step 4 Your spouse prints the Form of Payment option that has been agreed upon in the third space after “Form of Payment.”

Step 5 Your spouse prints the name of the agreed upon beneficiary in the space designated “beneficiary’s name”, even if your spouse is the beneficiary. This blank must be filled in even if selecting Form of Payment A. If you desire to name no one as a beneficiary, PERA will accept language such as “no one” or “n/a”. If no beneficiary is named, member contribution balances will be paid to the retiree’s estate upon death.

Step 6 Your spouse must sign and date this document in front of a notary public.

Step 7 The following must be filled in by the notary public: The notary public must write down in which county they are signing the

document. The notary must print your spouse’s name in the space designated

“spouse’s name.” The notary must fill out the complete date. The notary must fill in his/her term expiration date. The notary must either imprint or stamp this document. The notary must sign his/her name in the space designated “Notary

Signature.”

Step 8 The retiree must sign and date this document in the Notarization of Retiree’s Signature section in front of a notary public.

Step 9 The following must be filled in by the notary public: The notary public must write down in which county they are signing the

document. The notary must print the retiree’s name in the space designated

“retiree’s name.” The notary must fill out the complete date. The notary must fill in his/her term expiration date. The notary must either imprint or stamp this document. The notary must sign his/her name in the space designated “Notary

Signature.”

33 Plaza La Prensa, Santa Fe, New Mexico 87507 (505) 476-9401 fax (505) 476-9300 voice

(800) 342-3422 Toll-Free www.nmpera.org

*DDF*

PERA ID or SSN:

FIRST NAME MI LAST NAME

MAILING ADDRESS - Check box for Address Change HOME or CELL TELEPHONE NO.

CITY STATE ZIP

March 2017

Please select one: Member

PERA DIRECT DEPOSIT AUTHORIZATION FORM

Please select one: New Form Change In Existing Information

I Receive a Benefit as a Beneficiary

You are hereby directed to electronically transfer my monthly benefit check to the:

Name of Financial Institution:________________________________________

Account Number:__________________________________________________

Type of Account: Checking Savings

I authorize PERA to make credit and debit entries to my account at the above named financial institution. I agree to notify PERA immediately upon discovery of any errors resulting from transactions under this authorization and of any changes that may affect these instructions. I agree to hold PERA and the State of New Mexico harmless from any and all loss, cost, damage, or expenses suffered as a result of errors in credit or debit entries caused by persons not employed by PERA. I direct the above named financial institution to refund to PERA any deposits made to my account after my death in accordance with the agreement set forth below.

Your Signature:_______________________________________________ Date:_________________________________

Financial Institution Use Only: THIS MUST BE COMPLETED BEFORE BEING SUBMITTED TO PERAAgreement of Depository Financial InstitutionIn accordance with the authorization of the depositor, we hereby agree to credit and debit to depositor's account, benefit payments and corrections made by the New Mexico Public Employees Retirement Association without depositor's endorsement. We further agree to repay and refund to PERA on demand, the total amount of any such payments received and deposited to the account of the depositor, the due date of which occurs subsequent to the death of the depositor, and agree to accept the certification of PERA as sufficient evidence of the date of death of the depositor. By signature hereon we have verified the account number of the depositor.

Financial Institution Routing Number:____________________________________________________ Confirmation of Customer's Account Number:_____________________________________________ Name of Financial Institution:__________________________________________________________ Address:_____________________________City:__________________State:_________Zip:_______

Authorized Signature:___________________________________Date:_________________________YOU MUST ATTACH A VOIDED CHECK HERE OR A COMPLETED DIRECT DEPOSIT FORM FROM YOUR BANK (Please do not include a copy of a deposit slip)

33 Plaza La Prensa, Santa Fe, New Mexico 87507 (505) 476-9401 fax (505) 476-9300 voice

(800) 342-3422 Toll-Free www.nmpera.org

*TDF*

MEMBER INFORMATION – PRINT CLEARLY PERA ID or SSN:

FIRST NAME MI LAST NAME MAILING ADDRESS HOME or CELL TELEPHONE NO.

CITY STATE ZIP

March 2017

Check One: New Change In Existing Information

CHECK ONLY THE APPLICABLE BOXES

AUTHORIZATION

PERA TAX DEDUCTION FORMInstructions: This form must be completed in its entirety and returned to PERA for processing. Additional instructions are on the back page.

I submit this PERA Tax Deduction Form specifying what deductions I authorize to be made from my PERA retirement benefit for Federal and New Mexico State Income Tax purposes.

SIGNED __________________________________________ DATE _____________________________

NMRHCA Medical Plan Monthly Premium Contributions for January 1, 2018 - December 31,2018 (applicable if retirement date is after June 30, 2001)

Medical Plan Rate Calculation Instructions

1. Select a medical plan for the retiree; enter the rate from the Retiree Rate row that corresponds with your years of service. 2. If you are enrolling your spouse or domestic partner, select a medical plan for him/her; enter the rate from the Spouse Rate row that corresponds with your years of service (or, if your spouse/domestic partner is also an NMRHCA-eligible retiree, use the Retiree Rate that corresponds with your spouse’s/domestic partner’s years of service). 3. If you are also enrolling children, enter rate from Child Rate row multiplied by number of children. (# of Children: ________ x Child Rate: __________ = Total for Child(ren): _________ 4. TOTAL #1, #2, and #3.

$___________ Retiree + $___________ Spouse/ Domestic Partner + $___________ Child(ren) = $___________ Total

Voluntary Coverage Premiums

DENTAL PLAN Monthly Premium*:  Effective January 1, 2017 to December 31, 2017 

SINGLE TWO-PARTY FAMILY Delta Dental Basic  $18.51 $34.72 for both $ 58.15 for all Delta Dental Comprehensive  $41.32 $78.52 for both $126.75 for all United Concordia Basic  $16.80 $31.91 for both $ 47.87 for all United Concordia Comprehensive  $34.28 $65.12 for both $ 97.65 for all

VISION PLAN Monthly Premium*:    Effective January 1, 2017 to June 30, 2017 

Davis Vision  $ 4.76 $ 8.98 for both $13.23 for all DEPENDENT CHILD LIFE Monthly Premium*:  Effective January 1, 2016 to December 31, 2017 

The Standard Insurance  $2,500 - $3.83 for all $5,000 - $7.15 for all $10,000 - $13.83 for all

RETIREE/SPOUSE SUPPLEMENTAL LIFE Monthly Premium*:  Effective January 1, 2016 to 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 35‐39  $ 0.68 $ 0.86 $ 1.05 $ 1.23 $ 1.41 $ 1.87 $ 2.32 $ 4.14 $ 4.69 $ 5.96 Age 40‐44  $ 0.79 $ 1.08 $ 1.38 $ 1.67 $ 1.96 $ 2.69 $ 3.42 $ 6.34 $ 7.22 $ 9.26 Age 45‐49  $ 1.03 $ 1.56 $ 2.08 $ 2.61 $ 3.14 $ 4.46 $ 5.78 $ 11.06 $ 12.64 $ 16.34 Age 50‐54  $ 1.36 $ 2.22 $ 3.07 $ 3.93 $ 4.79 $ 6.94 $ 9.08 $ 17.66 $ 20.23 $ 26.24 Age 55‐59  $ 1.92 $ 3.34 $ 4.77 $ 6.19 $ 7.61 $11.17 $14.72 $ 28.94 $ 33.21 $ 43.16 Age 60‐64  $ 2.23 $ 3.96 $ 5.70 $ 7.43 $ 9.16 $13.49 $17.82 $ 35.14 $ 40.34 $ 52.46 Age 65‐69  $ 4.05 $ 7.61 $11.16 $14.72 $18.27 $27.16 $36.04 $ 71.58 $ 82.24 $107.12 Age 70 and over  $ 5.95 $11.40 $16.85 $22.30 $27.75 $41.38 $55.00 $109.50 $125.85 $164.00 *This is optional coverage, and the entire cost of coverage is paid by you. Cost of insurance for all coverages paid by you may increase or decrease in the future based upon the claims experience of participants.  All provisions that apply to this coverage are governed by the Certificate.  The life plan rates include a $.50 administration fee.   **Evidence of Insurability Statement required to add or increase life insurance.  The form can be found at http://www.standard.com/mybenefits/newmexico_rhca.