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Police
and Firemen's Retirement System
Retirement Forms
and Instructions
Instructions for
the Request for Retirement Estimate
The
Request for Retirement Estimate is intended to be used
as a tool for retirement planning. The member is under no
obligation to retire when a form is submitted. In fact,
it is not unusual for the Division to receive multiple estimate
requests from a member who is exploring the consequences of retirement
on several different dates. The only limitation is that
the estimate is received before a projected retirement date, and
not more than two calendar years in advance.
Membership
Number, Social Security Number, Name, Birth Date, and Address
This basic biographical
information will enable the Division to access the member's account
and process the estimate request. The Division will also
mail a copy of the estimate to the address listed on the request
from.
The question that asks
if the member has retired previously from the PFRS will enable
the Division to offer a more complete statement of estimated retirement
benefits.
Retirement
Type
The member must choose
the "type" of retirement for which an estimate is needed.
Discussion of the several types of retirement are listed on the
PFRS Retirements page.
If a member is eligible
for more than one type of retirement, a separate estimate may
be requested for each type. A separate estimate form is
required for each type of retirement selected.
Planned
Retirement Date
All retirements under
the PFRS must commence on the first of the month. An estimate
may be generated for requests up to two calendar years in advance
of the date of request.
Date
of Termination of Employment
For a retirement to
be approved, a retirement applicant must have terminated the relationship
with the employer no later than the day before the date of retirement.
In other words, all service must have ceased before a retirement
date, even if there are still payments outstanding in the payroll
system.
Most members plan to
work until immediately before retirement. Some members,
however, may choose to terminate their employer/employee relationship
well in advance; for example, a member contemplating a Deferred
Retirement. Because the date of termination of employment
will affect the accumulation of service credit in a member's account,
be sure to include the anticipated date of termination on the
estimate request.
Spouse's
Name and Birth Date
There are specific widow/widower
benefits for survivors of PFRS retirees. By providing this
information, the Division will be able to provide an estimate
of any survivor benefits after retirement. If the member
is unmarried or divorced, a "N/A" should be inserted
here.
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Instructions
for the PFRS Application for Retirement Allowance
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Retirement Application
- PFRS
The
PFRS Application for Retirement Allowance is completed
in its entirety by the member.
Part One: Member Information,
Retirement Date and Type, Spouse/Dependent Information
The
membership number is the first item required on the application.
Items
1-8. Member Information
The items on the first page of the
application request the member's name, address, employer name,
job title, Social Security number, date of birth (proof
of age will be required from the member if it has not already
been submitted), and the member's phone numbers at home and work.
Item
9. Outstanding Loans
The
member needs to inform the Division if an outstanding loan will
be "carried" into retirement or will be paid in full
prior to retirement.
- All retirees may 'carry' their
loans into retirement at the same monthly repayment level as
when they were active members.
- Biweekly loan payment schedules
are converted to monthly payments by multiplying the biweekly
payment by 2.175.
- The member may choose to pay
off the loan in a lump sum.
- Interest will continue to accrue
at 4.00% if the member chooses to "carry" the loan
into retirement.
Item
10. Effective Retirement Date of Member
Provide
t he effective date of the retirement (always the first of a month).
The application must be received in the Division prior to the
member's effective retirement date.
Item
11. Type of Retirement Requested
Service:
Age 55, any number of
years of service credit. Click
here for more information about Service Retirement.
Special: Twenty-five (25)
years of service credit, regardless of age. Click
here for more information about Special Retirement.
Deferred: Ten or more years
of Service Credit but under age 55. Click
here for more information about Deferred Retirement.
Item
12. Member's Marital Status.
Items 13-15. Spouse's Name, Maiden
Name, Social Security Number and Birth Date
This information is required if either
married or separated. If not married at the time of retirement,
this space may be left blank, or write "N/A."
Item
16. Name, Gender, Birth Date and Social Security Number of Eligible
Dependent Children
List all dependent children who are
under age 18, or those who are mentally or physically handicapped
regardless of age. Copies of birth certificates, adoption
papers, and medical documentation proving disability are required
for each child listed.
If additional space is needed, the
member may attach additional sheets. If additional sheets
are needed to list dependent children, these also must be notarized.
Part Two: Designation
of Group Life Insurance Beneficiaries
Group
Life Insurance
Non-disability retirees must have
at least 10 years service credit to qualify for Group Life Insurance
Death Benefits. Disability retirees qualify upon retirement approval
if they have life insurance as active members.
Primary Beneficiary(ies)
Those listed here receive the group
life insurance, if any, at the time of death. If the member chooses
multiple primary beneficiaries and one beneficiary predeceases
the member, the remaining beneficiary(ies) will usually share
that beneficiary's portion. Some special designations are allowable,
but uncommon. Unless otherwise stated, if multiple beneficiaries
are listed, they are considered "share and share alike"
applies. If the member had no active group life insurance coverage
through the pension fund, then the member will not have group
life insurance coverage as a retiree.
The following information should
be provided:
Contingent Beneficiaries
Contingent beneficiaries are paid
only if all the primary beneficiaries predecease the member. The
same information is needed for these beneficiaries as for the
primary beneficiary(ies).
Additional primary or contingent
beneficiaries can be listed on an attached and signed sheet.
Signature of Applicant
The application must be signed or
it cannot be processed. If any additional sheets for the retirement
application are attached, then these additional sheets must also
be signed.
Retirement applications no longer need to be notarized, effective
June 1, 2001.
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Certification
of Service and Final Salary, PFRS Retirements
The certification form
is completed by the member's employer.
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Completing
the Certification of Service and Final Salary
Item
1. Name of Member
Item
2. Membership Number
Item
3. Social Security Number
Item
4a. Name of Employing Agency
Item
4b. Pension Location Number
May be obtained from the PFRS Quarterly
Report of Contributions or any Certification for Payroll
Deductions received from the Division of Pensions and Benefits.
Item
5. Date of Termination of Service
This certifies that the member will
not render any service or earn any salary after this date.
Item
6a. Is the member currently on suspension?
If this is answered YES, the employer
is to state the date suspension began and mark the box stating
if the member is PAID or UNPAID while on suspension.
Item
6b. Is the applicant facing disciplinary action or indictment?
If this is answered YES, a detailed
explanation must be submitted by the employer. The Division
will review the explanation to determine if it is sufficient for
continued processing, if additional information is needed, or
if submission to the PFRS Board of Trustees is required.
IF either 6a or 6b are answered with
YES, copies of the preliminary and final notices of disciplinary
action, or the equivalents, or a copy of the indictment should
be included.
Item
7. Unpaid Leaves of One Month or More, within the Last Twelve
Working Months
This information shows when there
are gaps in service due to leaves of absence (LOA). Some LOAs
can be purchased by the member. A LOA for a work-related incident
may indicate a possible Worker's Compensation claim. If Worker's
Compensation is determined, the employer may be required to submit
pension contributions until retirement, on the member's behalf.
Item
8. Base Salary Subject to Pension Fund Contributions Paid for
the Last Full Year of Service.
The last 12 months of salary must
be indicated. Salary should be reported by the number of months
at a given salary, the amount of the monthly base salary, the
beginning and ending dates of that salary and the total base salary
for the period. Salary is being certified in advance. Therefore
salary not yet paid is to be projected to the best of the employer's
ability.
Item
9. Has the member received a significant annual salary increase
in the last three years of employment?
If the answer is yes, the employer
must furnish cause for the increase, with documentation.
The Division may approve the increase, if justifiable, deny the
increased salary, or forward the case to the Board of Trustees
for determination.
Item
10. Has there been any retroactive salary paid to the employee
within the past three years?
A retroactive salary increase can
falsely inflate a member's salary if it is not properly credited
back to the correct dates. Retroactive salaries can also incorrectly
show a single salary increase, when in fact it may cover several
years of increases. The beginning and ending dates should show
for each retroactive increase along with the corresponding
new annual base salary.
If the member receives a retroactive
raise after the original Certification has been sent to the Division,
a new Certification must be sent in. The new Certification should
state 'Amended' or 'Revised for Retroactive Increase.'
Item
11. Pension Deductions for Final Three Quarters
Enter the pension deductions that
have been made or will be made by the member in the three quarters
prior to retirement, including the quarter in which the member
retires. This will allow the Division of Pensions and Benefits
to calculate the member's retirement allowance in advance and
pay the retiree in a timely manner.
State employers must attach
a screen print of the member's TREADHOC biweekly certification,
with salaries projected until termination date, in lieu of completing
Item 11.
Completed By:
Denotes who actually completed the
form.
Phone Number
The Division requires the phone
number of the person who completed the form. This number allows
us to directly contact the employer for any follow up questions
we may have on the Certification.
Signature of Certifying Officer
The Certifying Officer is the individual
who certifies that this information is correct. Each location
has one Certifying Officer. This signature must be an original
signature and cannot be a stamped signature.
Date
Please give the date when the form
was signed by the Certifying Officer. The date signed is helpful
when more than one Certification is received by ensuring that
the most recent Certification is used. Usually more than one Certification
is received when there is a retroactive raise (marked "Revised
for Retro" or "Retroactive Raise"), or a change
in the Certification (marked "Amended").
NOTE CONCERNING WORKERS' COMPENSATION:
If the member is receiving periodic payments from Workers'
Compensation, the employer may be required to pay the member's
pension contributions until the member's effective date of retirement.
No loan payments, back deductions, or arrears payments are required
from the member or the employer while the member is on Workers'
Compensation. Whenever possible, an official statement of the
Workers' Compensation award, showing the amount of the periodic
benefits and the beginning and ending dates of the benefits awarded,
should be attached or mailed in under separate cover.
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Instructions for
the PFRS Application for Disability Retirement
Instructions
for Completing the
PFRS Application for Disability Retirement
The Application For Disability
Retirement is completed in its entirety by the member. The
member's signature must be present. The signature will be verified
when the application is keyed into the Division's system.
Items
1-6. Basic Member Information
Items 1-6 request basic member information,
including membership number, Social Security Number (SSN), member's
name, date of birth, (proof of age will be required from the member
if it has not already been submitted), member's home mailing address,
and home and work phone numbers.
Item 7. Member's Official Work
Title
Item 7 asks for with the official
work title under which the member is currently employed.
Item 8. Type of Disability Retirement
The type of disability
retirement requested: Accidental Disability versus Ordinary Disability.
(See also Fact
Sheet #16.)
Item 9: I declare that I am incapacitated
for further service in the work title listed in Item 7 due to
the following reasons:
This question should be answered
by the member, explaining in what way a disabling condition prevents
continued service in the job title listed in Item 7. This
should be completed in the member's own words, and should reflect
the pertinent job duties that fall under the specific job title.
Item 10. Retirement Effective
Date
The effective date of the retirement
(always the first of a month) should be provided. The application
must be received by the Division prior to the member's effective
retirement date.
Item 11. If you will have an outstanding
loan balance at retirement, how do you want to pay the loan off?
- All retirees can 'carry' their
loans into retirement at the same monthly repayment level as
when they were an active member.
- Biweekly loan payments are converted
to monthly payments by multiplying the biweekly payment by 2.175.
- The member can still pay off
the loan in a lump sum.
- Interest will continue to accrue
at 4.00% if the member chooses to 'carry' the loan into retirement.
Item 12. Are you currently under
departmental charges of formal indictment?
If the member is under charges or
formal indictment, additional information will be required from
the employer and/or the member. Delay in receiving this information
could delay the processing of the member's pension.
Item 13. Employer Name
Enter the official name of your current
employer.
Item 14. County
In which county is your employer
located?
Items
15 and 16 must be completed for Accidental Disability Only.
Item
15. Date of Accident and Description
The date of accident will be the
date of the traumatic event that directly caused the totally and
permanently disabling condition.
The accident description and list
of witnesses provides the member the opportunity to tell in his
or her own words valuable information that may prove helpful in
determining eligibility for an Accidental Disability Retirement.
Item 16. Has a Claim Been Filed
for Workers' Compensation?
If yes, then the member must attach
a copy of the award. The member should complete questions 16a,
16b and 16c:
- Amount of Periodic Benefits
(stated as a weekly dollar amount),
- Beginning Date of Award
(when the award was effective) and
- Ending Date of Award (when
the award's benefit concludes).
If the member has filed for Workers'
Compensation and the award is still pending, the member should
forward the information to the Division as soon as possible. (See
Fact Sheet #45)
PART
TWO: MARITAL STATUS AND CHILDREN
Item
17. Marital Status
Indicate here the member's marital
status.
Item 18. Name of Spouse
Leave blank or write N/A if none.
This information is needed for the letter to the member's spouse
notifying the spouse if the member takes the Maximum Allowance
pension benefit (sent certified mail). Divorced or ex-spouses
do not need to be listed.
Item 19. Spouse's Social Security
Number
Not required, but helpful information
in the event the retired member predeceases the spouse. This information
will enable the Division of Pensions and Benefits to process a
claim for death benefits as quickly as possible.
Item 20. Spouse's Address
Only needed if it is different than
the member's mailing address.
Item 21. Name, Gender and Birth
Date of Eligible Dependent Children
List all dependent children who are
under age 18, or who are mentally or physically handicapped regardless
of age. Copies of birth certificates, adoption papers, and
medical documentation proving disability are required for each
child listed.
If additional space is needed, the
member may attach additional sheets. If additional sheets
are needed to list dependent children, they also must include
all necessary information.
While not specifically requested,
inclusion of the Social Security numbers of dependent children
can be helpful in the event a death claim will be paid to them
upon the member's death.
PART
THREE: DESIGNATION OF GROUP LIFE INSURANCE BENEFICIARY
Item
22. Primary Beneficiary(ies)
The primary beneficiary(ies) listed
will receive the member's group life insurance. The coverage amount
varies according to the fund and level of coverage as an active
member.
The following information is needed:
Beneficiary's name, address, date of birth
and the beneficiary's relationship to the member (spouse,
daughter, son, father, mother, friend, grandchild, etc.).
If the member chooses multiple primary
beneficiaries and one beneficiary predeceases the member, the
remaining beneficiary(ies) will usually split that beneficiary's
share. Some unusual designations are allowable, but uncommon.
Unless otherwise stated, if there are multiple beneficiaries listed,
they are considered "share and share alike."
Item 23. Contingent Beneficiary(ies)
In the event all primary beneficiaries
have predeceased the member, the group life insurance benefit
will be paid to all listed contingent beneficiaries on a "share-and-share-alike"
basis, unless otherwise provided for.
In the event all contingent beneficiaries
have also predeceased the member, the group life insurance benefit
will be paid to the member's estate.
The following information is needed:
Beneficiary's name, address, date of birth
and the beneficiary's relationship to the member
(spouse, daughter, son, father, mother, friend, grandchild, etc.).
Member Signature
The member must sign the application.
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Instructions for
Medical Examination by
Personal or Treating Physician
Instructions for
the Medical Examination By Personal
or Treating Physician Form
After completing Part Two,
the physician may forward the form directly to the Division of
Pensions and Benefits at the address listed on the top of the
first page. Or it may be submitted with the Disability Retirement
application by the member.
It is essential that all relevant
medical information be submitted to the Disability Review Section
at the Division of Pensions and Benefits before adequate determination
of eligibility for Disability Retirement can be made. Any
delay in receiving this (or any) form will only delay processing
of the retirement.
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Instructions for
Completing
Authorization for Release of Medical Records
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Instructions for
the
Authorization for Release of Medical Records Form
Medical records pertaining to any
hospitalization(s) related to the disabling condition must also
be submitted to the Division of Pensions and Benefits.
- If no hospitalization occurred,
then medical examination reports from at least two physicians
must be submitted before a determination of disability can be
made. This form is still required by the Division of Pensions
and Benefits even if there was no hospitalization.
- The member may make as many copies
of this form as necessary in order to obtain records from more
than one hospital.
- The member must submit this form
directly to the hospital requesting the needed records.
- The member also assumes all responsibility
for any charges levied by the hospital for reproducing and/or
forwarding these records to the Division of Pensions and Benefits.
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Employer Certification
for Disability Retirement
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Instructions for
Employer Certification for Disability Retirement
Item 1.
Pension Fund
Please check to appropriate box
denoting the Pension Fund the member belongs to.
Item
2. Basic Member Information
This is self explanatory. Include
name of the employee, job title (including a copy of the job description),
Social Security number, name of employing location, employer address
and phone number.
Type of Disability Retirement
Check to box that corresponds to
the type of Disability Retirement the member is applying for.
Item
3. Employee Status
Please check the box that is appropriate.
To determine full-time status, refer to the regulations that pertain
to your location. For example, 35 or 40 hours per week.
Item
4. Authorized Leave of Absence
Review attendance records to determine
if the member has been on an authorized leave of absence within
the past year. Check all that apply. This will help the Division
of Pensions and Benefits determine the member's final salary.
Item
5. Unauthorized Leave of Absence
Please indicate if the member was
out on an unapproved leave and, if so, the duration of the leave.
Item
6a. Is the member currently on suspension?
It is very important that you answer
this question, even if the answer is "No". If the answer
is "Yes", be sure to include the date of suspension
and any documents that describe the reasons and circumstances
surrounding the suspension. By law, the Division cannot process
a retirement unless and until all information concerning suspensions
are submitted. Be sure to indicate if a suspension is paid or
unpaid.
Item
6b. Is the applicant facing disciplinary action or indictment?
Again, it is essential that you answer
this question, even if the answer is "No". If the answer
is "Yes", you must attach copies of all documents that
pertain to the disciplinary action or indictment, including preliminary
and final notices of disciplinary action or their equivalents.
Failure to answer questions 6a and
6b will only delay the processing of the applicant's retirement.
Item
7. Was the applicant dismissed?
As with lines 6a and 6b, this question
must be answered "yes" or "no". If yes, you
must give the reason and date of dismissal. This may have a direct
bearing on the outcome of the member's application for retirement.
Item
8. If Employee is Filing for an Accidental Disability Retirement
Since an Accidental Disability Retirement
is granted only for those who suffer a "Traumatic Event"
during the course of regular job duties, accident reports taken
by the employer are exceptionally important. Please answer the
questions on the basis of official records relating to the accident.
Be sure to include copies of any
pertinent documentation including an accident report, witness
statements, etc.
The question concerning Workers'
Compensation is very important. If a case has been settled
or is still pending, please attach a copy of all documentation
you may on file. This is essential information that may corroborate
the applicant's eligibility for Accidental Disability Retirement,
and may influence the calculation of the member's retirement allowance.
Item
9. Date Employee's Service Terminated
This is the last date on which the
employee earned or will earn salary from employment.
Item
10. Base Salary Subject to Pension Fund Contributions
Last 12 months (10 months if applicable)
of salary must be indicated. Salary should be reported by the
number of months at a given salary, the amount of the monthly
base salary, the beginning and ending dates of that salary, and
the total base salary for the period. Salary beyond the last reported
quarter is to be projected to the best of the employer's ability.
Item
11. Has the member received an annual salary increase of 10% or
more in the last three years?
If the answer is yes, the employer
must furnish cause for the increase along with documentation.
The Division may approve the increase, if justifiable, deny the
increased salary, or forward the case to the Board of Trustees
for determination.
Item
12. Retroactive Salary Increases in the Last Three Years
A retroactive salary increase can
falsely inflate a member's salary if it is not properly credited
back to the correct dates. Retroactive salaries can also incorrectly
show a single salary increase, when in fact it may cover several
years of increases. The beginning and ending dates should show
for each retroactive increase and the corresponding new
annual base salary.
If the member receives a retroactive
raise after the original Certification has been sent to the Division,
a new Certification must be sent in. The new Certification should
state 'Amended' or 'Revised for Retroactive Raise.'
Item
13. Salary Deductions during Final Quarters
The employer indicates the actual
and/or projected base salary subject to pension contributions
for the last two quarters preceding the member's termination date.
Also noted in this section are the amounts of actual and/or projected
payroll deductions for: pension contributions, loan repayment,
back deductions (including the number of payments taken), arrears
(and/or purchases) deductions, and the total pension deductions
taken (and/or projected to be taken) by the employer and remitted
to the Division for this member.
State employers must attach
a screen print of the member's TREADHOC biweekly certification,
with salaries projected until termination date, in lieu of completing
Item 11.
Checklist
This is a helpful tool printed on
the form to remind you which forms and documents to include with
the Disability Retirement Certification.
Be sure to include a letter addressed
to the Division of Pensions and Benefits stating that you (the
employer) believe that the member is totally and permanently disabled
for his or her job title.
Name and Signature of the Certifying
Officer
Each location has one Certifying
Officer.
The Certifying Officer is the individual
responsible for providing this information at each location. The
Certifying Officer must sign the Certification of Service and
Final Salary confirming that the information is correct. This
signature must be an original signature and cannot be a stamped
signature.
The date signed is helpful in processing
a retirement. When more than one Certification is received, the
Division can ensure that the most recent Certification is used
for processing. Usually more than one Certification is received
when there is a retroactive salary increase, or a correction is
made for mistaken information.
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