Leave of Absence Request Form. Forms & Publications. Spousal or Registered Domestic Partner Consent Form. FMLA Physician Certification Employee. For more information on the application process, beneficiary designation and benefits payable, please visit the CalPERS Website or contact them directly . If you ever have any questions, send us a message through myCalPERS or call us at 888 CalPERS (or 888-225-7377). SCP Distribution Request Form. Select the Save & Continue button. This form is used to request benefit changes, and/or update/change address and/or change the payment frequency on a current long term care insurance (LTCI) policy. CALPERS. Complete this form if you are currently employed (active) or an inactive member and you wish to designate a beneficiary or change your existing beneficiary designation for lump-sum benefits. Marriage/Registration of domestic partnership; or 2. my|CalPERS 1158. In the Beneficiary Designation Summary section, select the Benefit Type link. CalPERS Disabled Dependent Benefit (HBD-34) form to CalPERS for approval. E. Your Beneficiary Designation will be revoked automatically,and benefits will be payable to the closest survivor listed in section C,if any of the following events occur after your designation form is received by CalPERS: 1. Employers: To order a publication, log in to myCalPERS and select Requests above the left navigation column to . CalPERS Beneficiary Designation. Use our online form for Questions, Comments, & Complaints about CalPERS programs and services. Beneficiary Designation Details Page. Please print clearly. Tuition Reimbursement Request Form. In-Service Withdrawal Form. Internally, Savings Plus often refers to the 401 (k) and 457 . The advanced tools of the editor will direct you through the editable PDF template. Option 2 The beneficiary will receive a lifetime continuance of 100% of the benefit the member was receiving When the beneficiary dies, payments will stop and no further benefits will be paid. In the unfortunate event your spouse passes away, you must notify us so we can begin processing the death benefits. Change your lump-sum beneficiary designation any time through your personal my|CalPERS account or complete and mail the Post-Retirement Lump-Sum Beneficiary Designation or Post-Retirement Nonmember Lump-Sum Beneficiary Designation form. Pre-Retirement Lump-Sum Beneficiary Designation. In the Beneficiary Designation Details section, enter updated benefit distribution information. Marriage/Registration of Domestic Partnership; or 2. Beneficiary Designation Form - CalPERS (PDF) Beneficiary Designation Form - Life Insurance (Hartford) (PDF) Beneficiary - Designation of Check (PDF) 457 Deferred Compensation Contribution Change Form (PDF) 457 Deferred Compensation Rollover Form (PDF) 457 Deferred Compensation Enrollment Form (PDF) . SCP Death Distribution Request Form. Telephone: 510-628-3000 or 1-800-838-1932 Fax: 510-268-9574 Website: www.acera.org The beneficiary designation must be signed and submitted for review before it can be accepted by CalPERS. Having a designated beneficiary will ensure benefits are paid to the correct person in a timely manner. 241S) available from your personnel office or by calling CalPERS at (800) 352-2238.] CalPERS Supplemental Income 457 Plan BENEFICIARY DESIGNATION FORM 1. If you wish to designate a beneficiary other than the standard order stated above, you must request a beneficiary form from MetLife at 1-800-252-8524. Link 2022 Benefit Election Form Decline Coverage Acknowledgment Form Questionnaire for Disabled Dependent Benefit (HBD-98) CalPERS Medical Plan Election/Change Form (HBD12) Instructions for CalPERS Medical Plan Enrollment Form HBD12 Affidavit of Parent-Child Relationship Form (HBD-40) Medical Report for . PARS (For current or previous non-benefitted employees) Employee Hub Benefits website; click on the Deferred Comp & Retirement link then click on PARS Deferred Comp 457b plan Complete the PARS Designation of Beneficiary Form and submit to HR E. Your Beneficiary Designation will be revoked automatically, and benefits will be payable to the closest survivor listed in section C, if any of the following events occur after your designation form is received by CalPERS: 1. Death benefits are paid according to the valid beneficiary designation on file. IRC 415 (C) Limit Worksheet. CalPERS Special Power of Attorney Form. List of Beneficiaries Page. View additional information regarding retirement and log on to your online myCalPERS member account. SCP POFF Rollover Source Distribution Form. Beneficiary Designation Summary Page. LEAVE OF ABSENCE. BENEFICIARY DESIGNATION (CalPERS)* My l CalPERS 0772 Use to change: Person(s) designated to receive CalPERS benefits upon employee's death Note: Mail the completed form directly to the CalPERS address on the form. Certain death benefits allow you to name anyone you choose as a beneficiary. SPOUSAL CONSENT (If spouse/domestic partner is not the sole primary beneficiary) Your spouse/domestic partner must consent and acknowledge by signing below if he/she is not the sole primary beneficiary. Military Service Information - CalHR 190. Complete the . Beneficiary designations made after August 5, 2013 are available in myCalPERS. Having a Beneficiary Designation form on file will expedite the payment of your accumulated contributions and interest to your survivor. Change Beneficiary or Option Change After Retirement. Dental - The disability must have existed prior to reaching the age of 19. Forms from Section 400 of the Layoff Manual. The CalPERS Beneficiary Designation Form allows the member to designate Primary and Secondary Beneficiaries for payment of specific Death Benefits in the event the member dies before retirement. The benefits are payable to the following beneficiaries: A. Savings Plus is the name of the voluntary 401 (k) and 457 (b) Plans which began in 1974 as a long-term retirement savings program for most State of California employees. If you would like to update your beneficiary designation, please complete the Pre-Retirement Lump Sum Beneficiary Designation Form and mail to the address on the bottom of page 2 on the form. The Option Payee's Beneficiary Designation form remains in effect until a new form is filed. For the full Leave of Absence packet, contact your Personnel contact at your department or the Personnel Office. If you are an active member at the time of your death, and if you did not elect an option beneficiary to receive a my|CalPERS 0856 SCP Death Distribution Request Form. CalPERS Beneficiary Designation. my|CalPERS 0773. IRS form W-4P: Withholding Certificate for Pension or Annuity Payments: Indicate the correct Amount of Federal Income Tax to withhold from your payment(s). You must return the completed form to MetLife. PST (Part-time, Seasonal, Temporary Retirement Plan) . The CalPERS Beneficiary Designation form allows the member to designate Primary and Secondary Beneficiaries for payment of specific Death Benefits in the event the member dies before retirement. CalPERS Beneficiary Designation Form: Used to identify or change a PERS employee's beneficiary. Beneficiary Designation Form; California Public Employee's Retirement System (CalPERS) CalPERS Beneficiary Designation Form (This multi-part form is used to name a beneficiary to receive any CalPERS death benefits, if you should die before retiring.) Verification of Total State Service - CalHR 690. CalPERS Military Service Credit Options: Used to request service credit cost information for past active duty military service served prior to establishing CalPERS membership. The CalPERS 457 Plan allows you to automatically save a portion of your salary. designation, request a beneficiary designation form when you call. Contact us if you have questions about your account. Must be mailed to CalPERS Requires 2 witnesses and notarized. The benefits are payable to the following beneficiaries: A. Beneficiary Designations 6 If You Become Terminally Ill 7 . If you do not submit a designation form, Employee Action Form. RETIREMENT. The CalPERS Beneficiary Designation form allows the member to designate Primary and Secondary Beneficiaries for payment of specific Death Benefits in the event the member dies before retirement. 701C) CCPOA Benefit Trust Fund Primary Dental Plan IRC 415 (C) Limit Worksheet. Beneficiary Designation forms are available via the CalPERS' Web site www.calpers.ca.gov, or by calling our toll-free number, (888) CalPERS (225-7377). . Now, using a CalPERS - Beneficiary Designation Form - City Of Riverside - Riversideca takes a maximum of 5 minutes. 457 DEFERRED COMPENSATION. You may name a Trust as a primary or secondary beneficiary. INSTRUCTIONS In the event of your death, your 457 account will be paid to the primary beneficiary(ies) you name below. If your spouse is a CalPERS member or retiree, you should designate your beneficiary for your pension plan as early as possible. RECIPIENT DESIGNATION INSTRUCTIONS • REV 01/20 • PAGE 1 OF 2 DEFINED BENEFIT PROGRAM MEMBERS Use this form to designate recipients to receive the one- time benefit that may be payable in the event of your death. Employee Action Form. More information on CalPERS Beneficiary Designation. Please see your personnel officer for a description of the benefits. Employees may update beneficiary designations at any time using the Change of Beneficiary form below. A beneficiary is the person or entity that would receive the death benefit from your life . A signed copy will be returned to you for your records. Child 18 Care of Guardian - 242M Post-Retirement Beneficiary Designation Form. Select the Save and Continue button. CalPERS Beneficiary Designation Form. Decide on what kind of signature to create. SPOUSAL CONSENT (If spouse/domestic partner is not the sole primary beneficiary) Your spouse/domestic partner must consent and acknowledge by signing below if he/she is not the sole primary beneficiary. For personal account questions, . A convenient way to save. Please print clearly. As a member of CalPERS, employees also participate in Social Security. FLEXIBLE SPENDING ACCOUNT. If you leave CalPERS-covered employment, you may either: Retire. 241 (REV. If you want to designate different beneciaries for the different types of lump-sum benets, you will need to complete a new form for each type of designation. Use a check mark to point the choice wherever expected. Order. Helpful Links and Forms Library Your resource to learn about, enroll in . Social Security: As a member of CalPERS, employees also participate in Social Security. Please take a few moments to review the Death Benefits section of our website, where you'll find details about CalPERS death benefits, beneficiary designation, and more. The beneficiary designation may be changed at any time if the member has elected Option 1. Enter your official contact and identification details. CalPERS Pre-Retirement Lump Sum Beneficiary Form SPECIAL POWER OF ATTORNEY . Personal Information, Beneficiary Designation, Automatic Investment Change Form: Update a name, date of birth, marital status or beneficiaries, and/or initiate or change automatic investments. Leave of Absences. Health Benefits . 475 14th Street, Suite 1000, Oakland, CA 94612-1900 . This package contains information to help determine which benefits may be payable to a member's beneficiary and what forms must be filed in order to change the beneficiary or modify a CalPERS retirement benefit. as CalPERS, 401(k), 457(b) and/or 403(b) accounts, IRAs, etc. You can select to add a new beneficiary designation or view, upload, or replace a signed designation form. To request that a form be mailed to you, please call (714) 558-6200. Link Beneficiary Designation - CalPERS Beneficiary Designation - Nationwide Beneficiary Designation - VALIC Beneficiary Designation - County of Riverside Life Insurance Beneficiary Designation - Part-Time and Temporary Employees' Retirement Plan CalPERS Special Power of Attorney CalPERS Service Credit Purchase Options Retiree . CalPERS Supplemental Income 457 Plan BENEFICIARY DESIGNATION FORM BENEFICIARY DESIGNATION FORM / PAGE 2 of 3 4. Beneficiary Designation. To provide a lifetime monthly benefit to someone when you die, you can elect an option at retirement (this is different from the one-time death benefit). Pre-Retirement Lump-Sum Beneficiary Designation 888 CalPERS (or 888-225-7377) • TTY: (877) 249-7442 • Fax (800) 959-6545 Complete this form if you are currently employed (active) or an inactive member and you wish to designate a beneficiary or change your existing beneficiary designation for lump-sum benefits. Background Complete the CalPERS Beneficiary Designation Form & Special Power of Attorney Form and submit to HR. AD Transcript: https://www.calpers.ca.gov/docs/transcripts/calpers-quick-tip-beneficiary-designation.pdfDesignate a beneficiary to determine exactly who will. Download the Beneficiary Change Form and mail it to the address listed on the form. Select Active Members & Retirees and log in with your username and password Select the Retirement tab and then select Beneficiaries Select Add or Change Your Beneficiaries and follow the prompts You'll need information about your beneficiaries to complete the process, including Social Security numbers, birthdates, and addresses. You can find these forms in this publication or on our website at www.calpers.ca.gov. We are FSA Enrollment Form. beneficiary, obtain a CalPERS Beneficiary Designation Form from your personnel office, City Retirement Counselor or CalPERS On-Line. Update your beneficiaries As we've previously mentioned, you always want to be prepared should the unexpected occur. A completed Option Payee's Beneficiary Designation form must be received and accepted by CalSTRS prior to your death to be valid. my|CalPERS 1008. Request for Family Medical Leave Form. 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