Retirement Plan Selection Form for Faculty and Exempt Staff

PRINT
RESET
Retirement Plan Selection Form for Faculty and Exempt Staff
University of Maryland
Employee Name____________________________________
UMD Hire Date: ________________
Social Security Number _____________________________
___ Initial Hire ___ Rehire ___ Transfer (Name of Agency)____________________
Enrollment in a retirement program is mandatory by your first day of initial employment with the University of Maryland.
Regular status Exempt and Faculty employees are eligible to enroll in one of two retirement programs:
State Retirement & Pension System (SRPS)
Defined Benefit Plan – employees’ contribute a mandatory 7%
Handbook: “Employees’ and Teachers’ Reformed,
Contributory, and Non-Contributory Pension System”*
Required Enrollment Documents*:
o Membership Application (Form 1)
o Beneficiary Forms (Form 4)
Copy of US Passport, Drivers’ License/State Issued ID, Birth
Certificate
To be eligible for Health Benefits in Retirement, retirees of the
SRPS must have the following:
o 10 years minimum of creditable service
o If retiree has more than 10 years of creditable service,
but less than 25 years of creditable service, retiree
and spouse/dependents will receive a prorated
subsidy.
o 25 years of creditable service to receive the full
subsidy for Health Benefits for the retiree and
dependents.
Optional Retirement Program (ORP)
Defined Contribution Plan – UMD contributes 7.25% of
employees base annual salary, no mandatory employee
contribution
Handbook: “Choosing a Retirement Plan”*
Required Enrollment Documents*:
o Election Not to Participate in SRPS (Form 60)
o Vender Selection Form
Copy of Passport, Drivers’ License/State Issued ID, or Birth
Certificate
To be eligible for Health Benefits in Retirement, retirees of
the ORP must have the following:
o Retire directly with 10 years minimum of full-time
equivalent (FTE) ORP service
o Retire directly with 10 or more years of FTE ORP
service, but less than 25 years of FTE ORP service,
retiree only will receive a prorated subsidy. No
prorated subsidy for spouse/dependents.
o Ended service 25 years or more of FTE ORP service
to receive the full subsidy for Health Benefits for
the retiree and dependents
*Handbooks and Forms can be found online at www.sra.state.md.us and on the UMD-UHR website www.uhr.umd.edu
The above outline is for summary purposes only, full details are outlined in each of the respective retirement handbooks listed above.
It is important that you review and research both plans before making your election. Enrollment into an ORP is irrevocable. If you fail
to make an enrollment decision by your first day of employment, you will become “default enrolled” into the SRPS and the mandatory
contribution of 7% will be withheld from your paycheck. Contributions made to the SRPS as a result of the “default” enrollment will
not be returned to you until you either separate employment or reach retirement age (as defined by the Maryland State Retirement
Agency). Default enrollment into the SRPS requires that you complete the SRPS enrollment documents listed above. If you are
enrolled into the SRPS, you may change your election to the ORP within one year from your initial date of hire or eligibility date (for
those who converted from non-exempt to exempt/faculty, “eligibility date” is the effective date of such change in employment status).
Please note: Changing plans from the SRPS to the ORP may affect retiree health insurance subsidy calculation.
If you need additional information or have questions, please contact the UHR Office of Employee Benefits at 301.405.5654.
Please initial the applicable statement(s):
_____ I have never been enrolled in Maryland Optional Retirement Program (ORP)
_____ I have been previously enrolled in the Maryland Optional Retirement Program (ORP) at
_______________________________________(Name of Institution) from ________ (mm/yyyy) to ________ (mm/yyyy)
Please initial your Retirement Selection:
_____ I elect to enroll in the Optional Retirement Program.
_____ I elect to enroll into the Maryland State Retirement & Pension System.
By signing below, you acknowledge that you have read the above statements and that it is your responsibility to make an enrollment
decision by submitting the necessary enrollment documents to your department. Failure to make an enrollment decision by your first
day of employment will result in your becoming “default enrolled” into the Maryland State Retirement & Pension System, in which
Membership Forms will be due at that time.
_____________________________________________________
Employee Signature
__________________________________
Date
MARYLAND STATE RETIREMENT AGENCY
120 EAST BALTIMORE STREET
BALTIMORE, MD 21202-6700
APPLICATION FOR MEMBERSHIP
FOR RETIREMENT USE ONLY
IMPORTANT: PLEASE PRINT CLEARLY AND READ THE INSTRUCTIONS FIRST.
APPLICANT'S SOCIAL SECURITY NUMBER
GENDER (M or F)
–
FORM 001 (REV. 9/10)
DATE OF BIRTH
–
Month
APPLICANT=S NAME
First
HOME ADDRESS
Initial
Day
Year
Last
Number and Street
City
State
–
Zip Code
–
Home Phone Number
1.
2.
3.
4.
5.
Have you ever been a member of the Maryland State Retirement and Pension System? .............................................. Yes † No †
Have you ever been a member of the Optional Retirement Plan (ORP)? ........................................................................ Yes † No †
Are you presently receiving a retirement allowance from the Maryland State Retirement and Pension System? ............ Yes † No †
Are you presently a member of another State or local retirement or pension system operated under the laws of
Maryland or any political subdivision of Maryland?........................................................................................................... Yes † No †
IMPORTANT: If yes, read carefully the transfer provisions on the back of this form and then initial here: ________.
Have you attached acceptable proof of birth date as described on the back of this form?…………………………………….. Yes † No †
I certify that all statements made on this application are correct. I authorize any required deductions from my salary at the prescribed rate.
And if I am presently a member of another State or local retirement or pension system, I have read and understand the transfer provisions.
Complete Signature
Date Signed
RETIREMENT COORDINATOR COMPLETES THIS SECTION
A.
IS THE APPLICANT A PERMANENT EMPLOYEE? ....................................................................................................... Yes † No †
If part-time, what percentage of time is the applicant employed? ...............................................................
Day
B. When did applicant begin present continuous service?........................................... Month
C. What is the applicant=s complete job classification or title?
Year
percent
.
D. Is applicant’s current position Optional Retirement Plan (ORP) eligible? ............................................................................ Yes † No †
E.
F.
If yes and the applicant checked “Yes” to question 2 above, STOP and complete Form 60 Election Not to Participate in the
Teachers’/Employees’ System by Faculty or Administrative Officers of Institutions of Higher Learning.
What is the applicant=s annual standard hours?
What is the applicant=s annual salary? $
If applying for membership in the Law Enforcement Officers= Pension System, does the applicant meet the eligibility requirements?
......................................................................................................................................................................................... Yes † No †
G. Number of pay periods reported per year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
INDICATE SYSTEM:
† Teachers= Pension
† Employees= Pension
† State Police Retirement
EMPLOYING AGENCY CODE
# OF RETIREMENT
CONTRIBUTIONS
DEDUCTED PER YEAR
† Correctional Officers= Retirement
† Law Enforcement Officers= Pension
FOR RETIREMENT USE ONLY
SYSTEM
MO
DAY
YEAR
ENTRANCE DATE
RETIREMENT COORDINATOR SIGNATURE
DATE
TELEPHONE #
MARYLAND STATE RETIREMENT AGENCY
120 EAST BALTIMORE STREET
BALTIMORE, MARYLAND 21202-6700
DESIGNATION OF BENEFICIARY
IMPORTANT: PLEASE RETURN COMPLETED FORM TO THE ADDRESS LISTED ABOVE.
PRINT CLEARLY AND READ THE INSTRUCTIONS FIRST. FILL IN ALL
SECTIONS. RETAIN A COPY FOR YOUR RECORDS.
APPLICANT'S SOCIAL SECURITY NUMBER
B
Working
Vested
FORM 4 (REV. 3/11)
Retired (If retiring, retirement date ______________ )
IMPORTANT: If you are retired under Option 2, 3, 5 or 6, STOP. You cannot use this form. You
must complete a Form 66 to initiate any beneficiary changes.
B
APPLICANT=S NAME
HOME ADDRESS
CHECK ONE:
FOR RETIREMENT USE ONLY
First
Initial
Last
Number and Street
City
State
PRIMARY BENEFICIARY(IES) All money shall be paid in equal shares
to the primary beneficiary(ies) who are living at the time of my death.
BENEFICIARY=S NAME
RELATIONSHIP* _______________
Zip Code
Check if you used an additional Form 4
to name additional primary beneficiaries.
Gender:
Birthdate:
(M or F)
Month
Day
Year
First
Initial
Last
*If spouse, please indicate state/jurisdiction where marriage license was issued: ____________________________ Date of marriage: ___________
BENEFICIARY=S ADDRESS ______________________________________________________________________________________________
BENEFICIARY=S NAME
First
RELATIONSHIP _______________
Gender:
Birthdate:
(M or F)
Initial
Month
Day
Year
Last
BENEFICIARY=S ADDRESS ______________________________________________________________________________________________
CONTINGENT BENEFICIARY(IES) If all primary beneficiaries die before me all money shall
be paid in equal shares to the following person(s) who are living at the time of my death.
BENEFICIARY=S NAME
First
RELATIONSHIP _______________
Gender:
Birthdate:
(M or F)
Initial
Check if you used an additional Form 4 to
name additional contingent beneficiaries.
Month
Day
Year
Last
BENEFICIARY=S ADDRESS ______________________________________________________________________________________________
BENEFICIARY=S NAME
First
RELATIONSHIP _______________
Gender:
Birthdate:
(M or F)
Initial
Month
Day
Year
Last
BENEFICIARY=S ADDRESS ______________________________________________________________________________________________
TO THE MARYLAND STATE RETIREMENT AGENCY
I authorize the Maryland State Retirement Agency to pay the death benefit to my designated beneficiary or beneficiaries. I agree on behalf of my estate, heirs
and assigns that the payment made by the agency will release the agency from any further obligation regarding this benefit. I direct the agency to pay the
death benefit to my estate if I have not designated any beneficiary or if all of the primary and contingent beneficiaries I have named die before me. I understand
that I may change beneficiaries at any time by filing a new Designation of Beneficiary form with the Maryland State Retirement Agency. Any new Designation of
Beneficiary form I file will replace this form. I understand certain payment due to a minor shall be made only to the legal guardian of that minor.
SIGN IN THE PRESENCE OF A NOTARY PUBLIC. (Form not valid unless notarized.)
Signature
Date Signed _____________________________________________
State of __________________ County of __________________ (or City of Baltimore) On this
__________________ day of __________________, 20 __________________, before me, the undersigned
officer, personally appeared ____________________________________, known to me (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 ________
Official
Seal must
be affixed
Instructions: Application for Membership (Form 1)
PLEASE READ CAREFULLY BEFORE FILLING OUT FORM
Designation of Beneficiary (Form 4) should be completed and
submitted with this Application for Membership (Form 1).
Purpose of this form:
This form is your application for membership in the Maryland State Retirement and Pension System. If
you were previously enrolled in the Optional Retirement Plan (ORP) and are currently working in an
ORP-eligible position, you may not join the Maryland State Retirement and Pension System. When
complete, keep a copy for your records. Send the original to your Retirement Coordinator with proof of
your birth date. Submission of this form and supporting documents is not a prerequisite for
membership but is required for proper enrollment and reporting.
Acceptable Proof of Birth Date
Attach a visible and readable photocopy of one of the following as proof of your birth date:
•
•
?
Birth Certificate
Valid Driver=s License
•
•
United States passport
Naturalization records
•
Maryland identification
card
Are you presently a member of another State or local retirement or pension system operated
under the laws of Maryland or any political subdivision of Maryland? If so, the following
information may affect your future benefit:
Transfer Provisions for Service Credit Earned in Another Maryland
State or Maryland Local Retirement or Pension System
This provision addresses the situation involving a change in employment, which necessitates a
membership change in a retirement or pension system. Previous membership may be in a
retirement or pension system administered by the State Retirement Agency or by a political
subdivision within Maryland.
To qualify for the transfer of service credit, your employment must be continuous and you must
apply to transfer the qualified credit within one year of becoming a member of your new retirement
or pension system. Continuous employment as a requirement for transfer means that you changed
jobs without having a break in employment.
It is important to remember that any transfer of service credit must be done within one year
after becoming a member of your new system. The employee contribution requirements of your
new retirement or pension system determine the amount of employee contributions with interest
needed to accompany the transfer of service. Inadequate employee contributions will result in a
contribution deficiency on your account.
To transfer credit in another Maryland State Retirement and Pension System (SRPS) system
complete a Request to Transfer (Form 37). To transfer credit earned outside of SRPS, you must
complete a Request to Purchase Previous Service (Form 26). All forms can be obtained from your
Retirement Coordinator or from the SRPS Web site at www.sra.state.md.us.
Need Help?
If you need help to complete this form or clarification, please call a Retirement Benefits Specialist at
410-625-5555 (local) or 1-800-492-5909.
Insturctions: Designation of Beneficiary (Form 4)
PLEASE READ CAREFULLY BEFORE FILLING OUT FORM
1. Purpose of this form:
Active Members: Use this form to name the person
or persons (beneficiaries) you want to receive any
accumulated retirement contributions and death
benefits if you die while you are employed.
Vested Members: The person or persons you
designate on this form receive your accumulated
retirement contributions, if any. No death benefits are
payable upon the death of a vested member.
Retirees: Use this form only if you chose Basic
Allowance, Option #1 or #4. The person or persons
named receive one payment if your death occurs on
the 16th of the month or later (Basic Allowance), any
remaining portion of the present value of your benefit
(Option #1) or the remaining portion of your
accumulated contributions (Option #4).
If you are retired under Option 2, 3, 5 or 6, STOP. You
cannot use this form. You must complete a Request
for Calculation of Joint Survivorship by a Retiree
Considering Changing a Beneficiary (Form 66.) Please
see the Maryland State Retirement Agency (MSRA)
Web site at www.sra.state.md.us or call a Retirement
Benefits Specialist.
2. Changing beneficiaries:
You may change your beneficiaries at any time by
completing a new form and filing it with the Maryland
State Retirement Agency located at 120 East
Baltimore Street, Baltimore, Maryland 21202. You
must fill out a new form and file it with the MSRA each
time you add, subtract or change beneficiaries.
The most recent form on file at the Maryland State
Retirement Agency replaces any form(s) previously
filed with the MSRA.
3. Number of beneficiaries
Fill out only the spaces needed. If you need space for
more beneficiaries, complete another form and check
the box or boxes to show that you have used a second
form.
4. Full names of beneficiaries:
Give the full names of your beneficiaries. For example,
AMary [email protected], not AMrs. John [email protected]
5. Who can be a beneficiary:
Beneficiaries do not need to be related to you.
Your estate:
You may name Amy [email protected] Do not name a personal
representative of your estate as your beneficiary.
Instead, use the space for the beneficiary=s address to
show the address of the person or business that will
administer your estate.
Trustee:
If you have established an Agreement of Trust or
Testamentary Trust, you may name ATrustee as
appointed by Agreement of Trust or [email protected] in the space
provided for the beneficiary=s address. Give the
address of the Trustee or of the person or business
that will administer the trust.
Church or charitable organization:
List the complete corporate or legal name.
Monthly allowance for husband or wife:
If you die before retirement and your age and/or years
of service at death meet certain requirements, your
husband or wife is eligible to elect to receive either a
one-time payment or a monthly allowance. If you want
your husband or wife to be eligible to make this
election, you must name him or her as your only
primary beneficiary. You may still name contingent
beneficiaries, but they are not eligible for a monthly
allowance.
6. The total benefits due at your death are paid in equal
shares to the living beneficiaries named on your
Designation of Beneficiary form. If you name multiple
primary beneficiaries, and one of the primary
beneficiaries dies before you, the total benefits due at
your death are divided in equal shares among the
remaining primary beneficiaries. If all primary
beneficiaries die before you, and one of multiple
contingent beneficiaries also dies before you, then the
total benefits payable at your death are divided equally
among the remaining contingent beneficiaries.
A deceased beneficiary’s share of your total benefits
cannot be paid to that deceased beneficiary’s heirs.
Payment is made only to the living beneficiaries
listed on your Designation of Beneficiary form
7. Notarization
Sign in the presence of a Notary Public. This form
is not valid unless notarized.
Properly completed forms should be mailed to:
Minor children:
You may name minor children as beneficiaries, but in
some cases payments can only be made to the legal
guardian of a minor. You cannot use this form to
name a legal guardian for minor children.
Maryland State Retirement Agency
120 E. Baltimore St.
Baltimore, MD 21202-6700
NEED HELP?
IF YOU NEED HELP TO COMPLETE THIS FORM, CALL A RETIREMENT BENEFITS SPECIALIST
AT 410-625-5555 (LOCAL) or 1-800-492-5909 (TOLL FREE)
www.sra.state.md.us