CONTRA COSTA COUNTY
EMPLOYEES' RETIREMENT ASSOCIATION

 

APPLICATION FOR SERVICE RETIREMENT

               _________________________ 20 ______

In accordance with the provisions of the County Employees’ Retirement Act of 1937 and the regulations governing the Retirement Association, I hereby make application for retirement from active service as a:

__________________________________ in the ______________________________________
                   (Title of Position)                                         (Name of Department or Agency)

If you have Tier II service we will need an estimated allowance for age 62 from your local Social Security office.

I request that my retirement become effective on the _______ day of ______________ 20_____ except under provisions of California Government Code Section 31680.2, as those provisions are qualified by Federal law regarding “bona fide separation from service” before Normal Retirement Age.

I understand that I will be precluded from employment covered by this Retirement System after this date, except under provisions of Section 31680.2.

I was born ___________________; therefore, I am now              years old.  (Submit proof of date of birth)

If you are under 50 years old and your last tier before retirement was safety;
Or, if you are under 55 years old and your last tier before retirement was as a general member,
you must certify the following to CCCERA:

1. I do not have a prearrangement with my employer to be reemployed after retirement;
2. I understand that I may not be reemployed by my current employer for at least 90-days from the effective date of my retirement; and

I acknowledge if I am reemployed by my current employer without compliance as outlined in (1) or (2), my retirement benefits from CCCERA will cease and will not resume until I have a bona fide separation from service or reach my Normal Retirement Age, whichever occurs first.

If applicable, sign and acknowledge you agree with these statements:

                                                                          

I have _______________ years of service credit in the Retirement Association.

My present mailing address is _____________________________________________________
                                                                           (Number)                            (Street)
                                                 _____________________________________________________.
                                                                       (City)                                   (State)      (Zip)

My Social Security No. is ______________________. My telephone _____________________.
                                                                                                                (area code) – (number)

I nominate as my beneficiary __________________________________________________, my

________________________ , ____________________________________________________
             (Relationship)                                          (Full Address of Beneficiary)

whose date of birth is _____________ and whose Social Security No. is___________________.

___________________________________               __________________________________
Applicant - Print Name (first name in full)                   Signature of Applicant

___________________________________               __________________________________
Witness - Print Name (must be an adult)                      Signature of Witness