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Printable Forms

Contra Costa County
Employees' Retirement Association

These CCCERA forms can be filled out on line, then printed and sent to CCCERA. We cannot accept electronic submission of the forms at this time, due to the signature verification requirement. Verifying your signature protects the integrity of your personal account information. If you make a mistake entering your information, use the "backspace" button on your keyboard to correct the entry, or reset (erase) the entire form by clicking on the Reset Form button located at the bottom of each form.

Forms for Active Members:


Beneficiary Change
Please note: If you are married or a State of California registered domestic partner, by law, your beneficiary is your spouse/domestic partner, unless you have a signed, notarized, spousal/domestic partner waiver.

Address Change: District or Deferred Member
If you are a County employee, you must change your address with your payroll clerk.

Estimate Request
This is not a request to retire, but a request to estimate your benefit amount to assist in planning your retirement. CCCERA does not accept estimate requests unless the member is within 5 years of retirement. Estimates beyond that time are not practical, since important data used in calculating estimated benefits (such as salary and years of service) are too variable beyond 5 years.

Records Disclosure Authorization
This form authorizes the release and/or use of your personal information (member records) to a person you designate. The Authorization must be on file with CCCERA to be in effect, and can be revoked at any time.

Active Death Disability Retirement Application
This form allows eligible, active members to elect an Option 2 benefit prior to death. This election maximizes the post-death survivor benefit should the member die while in active service. Complete information on this form is available on the Survivor Benefits Page.

 

Forms for Retired Members:

 

Address Change
This form notifies CCCERA of changes to your mailing address.

Beneficiary Change
Please note: If you are married or a State of California registered domestic partner, by law, your beneficiary is your spouse/domestic partner, unless you have a signed, notarized, spousal/domestic partner waiver. (California state law mandates that opposite sex domestic partners must be 62 years of age or older. See Section 3B of the Family Code (297)).

Electronic Funds Transfer (EFT)
Changes to your Electronic Funds Transfer (i.e., if you change banks or accounts) require this form.

Federal and/or State Income Tax Withholding
Retired members have the right to change, start, or stop federal and/or state tax withholding from monthly benefit payments. A change can be made at any time by filing a new withholding authorization. Click here for information about the form.

Retiree Reinstatement to Active Membership
Use this form to suspend your retirement and reinstate as an active CCCERA member under Gov. Code Section 31680.4.