Forms for Active/Deferred Members
Submit original documents only.

General information

At this time, we cannot accept electronic submission of forms due to the signature verification requirement. Verifying your signature protects the integrity of your personal account information. Only original forms will be accepted (no copies).

Mail completed forms to:

CCCERA
1355 Willow Way, Suite 221
Concord, CA 94520

If you would like a form mailed to you, please call CCCERA or email info@cccera.org.

Active Member Forms (currently working for a CCCERA employer):

Welcome to CCCERA

New Member Enrollment Packet

Enrollment Affidavit (Form 101)

This form is filled out when a member accepts permanent employment with Contra Costa County or special district employers.

Beneficiary Designation Form (Form 102)

Please note, if you are not naming your spouse/registered domestic partner as 100% assigned primary beneficiary, your spouse/partner’s signature is required on the reverse side of this form in Section 4 and must be witnessed by a notary public. (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)).

Reciprocity Election Form (Form 103)

This form is used for members entering service as a reciprocal member.

Reciprocity Affidavit Form (Form 109)

This form is for new CCCERA members who may be eligible for reciprocity. Use this form only if you have indicated on your Enrollment Affidavit (Form 101) that you may be eligible for reciprocity. This form will help CCCERA determine your initial retirement plan placement, which will affect the amount of retirement contributions deducted from your paycheck.

Death During Active Membership (Form 104)

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.

Direct Trustee to Trustee Transfer (Form 105)

This form is used to make direct trustee to trustee transfers. To process the trustee-to-trustee transfer, this form must accompany any form(s) required by your Plan Sponsor, such as the Mass Mutual Form for Purchase of Service Credit

Request for Estimate (Form 108)

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.

Retirement Application Packet

This is a request to retire. Please note that applications should not be submitted any earlier than 60 days of retirement.

Release of Information Form (Form 304)

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.

Deferred Member Forms (not currently working for a CCCERA employer):

Deferred Member Mailing Address Change Form (Form 301)

Use this form to change your mailing address if you are not currently working for a CCCERA employer.

Active members (currently working for a CCCERA employer) cannot use this form; they must change their address with their employer. CCCERA receives address change information directly from employers.

Deferred Member Name Change Form (Form 302)

Use this form to change your name if you are not currently working for a CCCERA employer. In addition to this form, you must mail a copy of one of the following documents to verify your name change: driver license, social security card, marriage certificate.

Active members (currently working for a CCCERA employer) cannot use this form; they must change their name with their employer. CCCERA receives name change information directly from employers.

Important CCCERA Refund Tax Information and Special Tax Notice

This document contains information for members eligible for a refund or rollover of CCCERA contributions and/or interest. If all or a portion of a payment you are eligible to receive from CCCERA is eligible to be rolled over to an IRA or to another eligible retirement plan, this document can help you decide whether to do such a rollover.

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