updated 8.19.19
updated 8.26.19
Application for General Employees
Retirement Plan Benefit
Page 1 of 7
1.
2.
3.
Application for Retirement Benet (required)
The application must be signed by you and your spouse (if married)
in the presence of a notary.
Direct Deposit Agreement (optional, but recommended)
Complete this form to have monthly payments deposited into your bank
account. Generally, payments are deposited the rst business day of
each month.
Tax Withholding Certicates (default will apply if you do
not complete a Form W-4P and W-4MNP)
See page 6 of this form for more details about income tax withholding.
Photocopy of Birth Records (required)
Payment cannot begin until you provide a photocopy of your birth
record. In addition, if you select a survivor option, you must provide a
photocopy of your survivor’s birth record.
Photocopy of Marriage Certicate (if applicable)
Certied Copy of Divorce Decree(s) and Domestic
Relations Order(s) (If applicable)
If you are currently divorced or have ever been divorced, you must
provide these documents, even if the MSRS retirement benet will
not be divided between the parties.
You will receive your rst payment about 6 weeks after the
retirement benet start date indicated in Section 2 of this
application. Please plan accordingly. The rst payment may
be higher because it includes retroactive payments back to
your benet start date. After that, monthly payments will be
deposited into your bank account the rst business day of
each month. If payment is made by check, assume additional
time for mailing.
Timeline to receive payment
Generally, you must end all State of Minnesota
employment before receiving a retirement benefit.
If you are covered by multiple Minnesota
public pension plans, contact MSRS to discuss
your individual circumstances.
Things to know
The completed forms and required documents
must be mailed to MSRS (we cannot accept a
fax or email).
MSRS is unable to accept your application more
than 60 days prior to the retirement benefit start
date you indicate in Section 2 of this application.
For more information
• Refer to the Your Guide to Retirement brochure
• See the Guide to Apply for a Monthly Benet on pages 6 & 7
• Call MSRS at 651.296.2761 or 1.800.657.5757; or
• Visit our website at www.msrs.state.mn.us
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We realize that retiring is a signicant life event and want to make the process to apply for your MSRS retirement benet as
easy as possible.
Forms you need to complete and documents to provide:
Congratulations on your upcoming retirement!
updated 8.19.19
It is important that you understand your options. Please review the “Your retirement” section on page 6 of this application.
Last day on payroll:
Retirement benefit start date:
Your retirement
2.
Month Day Year
Page 2 of 7
Last name First name MI MSRS ID or SSN
Mailing address Date of birth
City State Zip code
Daytime phone Alternate phone
Current marital status
Single Married Divorced Widowed
Spouse’s name Spouse’s date of birth
Check this box if you have ever been divorced.
You must provide MSRS with a certified copy of your divorce decree(s) and domestic relations order (DRO), if applicable, even if the
benefit will not be divided between the parties.
1.
Information about you (please type or print)
You will receive your first benefit payment about 6 weeks after the retirement benefit start date you indicated above.
This timeline assumes:
• your application for retirement is in good order;
• you have provided MSRS with all required documents; and
• your employer has remitted all contributions to your retirement plan.
Failure to meet these requirements could delay your benefit payment.
Application for General Employees
Retirement Plan Benefit
Please complete pages 2 - 5 and mail the original application to MSRS. Refer to the Guide to Apply for a Monthly Retirement
Benefit beginning on page 6 of this application for information on how to complete this form.
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updated 8.26.19
Month Day Year
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3.
Retirement benefit option
Your retirement benefit is for your lifetime regardless of the option you select. If you choose joint-and-survivor coverage or the life income
option, you will receive a lower monthly benefit to provide this additional coverage. MSRS will send you a benefit authorization letter
confirming the monthly benefit amount about the time you receive the first payment. You may change your benefit option up to 30 days
after the date of the authorization letter. After that, you may not change your survivor option election.
See page 7 for a comparison of retirement benefit options.
4.
Survivor information
Survivor’s Name Social Security Number Relationship to you
Choose one option
Complete this section if you selected a Joint-and-Survivor Benefit or Life Income, 15-Year Period Certain option in Section 3.
DO NOT COMPLETE THIS SECTION IF YOU SELECTED A SINGLE-LIFE BENEFIT.
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Upon your death, your survivor will receive a monthly benefit for their lifetime
equal to your benefit amount.
Upon your death, your survivor will receive 75% of your monthly benefit for their
lifetime.
Upon your death, your survivor will receive one-half of your monthly benefit for
their lifetime. If you are married, Minnesota law requires that you provide at least
a 50% option for your spouse unless they waive survivor coverage.
If you die before collecting a monthly benefit for 15 years, your survivor will
continue to receive the benefit for the balance of the 15 years. If you die after
collecting a benefit for 15 years, your survivor will not receive a benefit.
Single-Life Benefit
100% Joint-and-Survivor Benefit
75% Joint-and-Survivor Benefit
50% Joint-and-Survivor Benefit
Life Income, 15-Year Certain
This benefit is for your life only and ends upon your death.
Proceed to Section 5.
Your survivor’s age may limit the survivor options available to you. Contact MSRS for details.
You must provide a photocopy of your survivor’s birth record if you selected a Joint-and-Survivor Benefit.
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5.
Income tax withholding
Some or all of your pension benefit is taxable income. You have the option to provide instructions to MSRS for federal and state tax
withholding. If no instructions are provided, the default withholding will apply.
Federal tax withholding Minnesota state tax withholding
MSRS staff members are unable to provide advice regarding tax withholding. You are encouraged to consult a tax advisor to determine
your appropriate income tax withholding.
• The default federal tax withholding assumes a filing
status of single and no adjustments (regardless of
your actual marital status).
• To choose an alternate income tax withholding
election (or no withholding), complete a Form W-4P
Withholding Certificate and submit to MSRS with your
retirement application. For more information, see
www.irs.gov.
• The default Minnesota tax withholding rate is 6.25%
(Minnesota residence only. MSRS cannot withhold
taxes for other states).
• To choose an alternate Minnesota tax withholding
election (specified percentage, dollar amount, or no
withholding) complete a Form W-4MNP Withholding
Certificate and submit to MSRS with your retirement
application. For more information, see
www.revenue.state.mn.us/withholding-annuities-and-pensions.
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Minnesota State Retirement System
60 Empire Drive, Suite 300
St. Paul, MN 55103-3000
6.
Notarized signature of applicant (and spouse if married)
Only the original application with signature and notary will be processed. A fax or email copy is not acceptable.
The date this form is signed must match the date your signature is notarized. Note: Notary seal must be visible.
MSRS is unable to accept your
retirement application more than 60
days in advance of the retirement
date you indicated on this application.
A. For Completion by Applicant
I have read the information on this application and understand that my
selection is for a retirement benefit. I further understand that the retire-
ment benefit option selected on this application can be changed up to 30
days after the date of the MSRS benefit authorization letter. I verify that all
statements made on this application are true and complete.
B. For Completion by Applicant’s Spouse
A married participant’s application will be delayed without a notarized
signature of the spouse.
I am the spouse of the applicant. I am aware that this retirement plan pro-
vides survivor benefit options available to protect me upon my spouse’s
death. I have read, understand, and agree to the survivor benefit option
selected by my spouse on this application. If I am not the survivor named
on this application, my notarized signature below acknowledges that I
agree to waive survivor coverage.
Signature of Applicant Date
For Completion by Notary
Subscribed and sworn to before me this
Day of , Year .
Signature of Notary
Notary Public of County.
My Commission expires
Signature of MSRS Representative Date
Notary Seal (Required)
In lieu of a notary, an MSRS retirement representative can witness
your signature.
Signature of Applicant’s Spouse Date
For Completion by Notary
Subscribed and sworn to before me this
Day of , Year .
Signature of Notary
Notary Public of County.
My Commission expires
Signature of MSRS Representative Date
Notary Seal (Required)
In lieu of a notary, an MSRS retirement representative can witness
your signature.
We provide Minnesota Retired State Employees Association (MRSEA)
with new retiree’s contact information. If you do not want us to share
your information with MRSEA, please check the box. To learn more,
visit www.mrsea.org
Mail the completed form to:
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Teletypewriter users and telecommunications-device-for-the-deaf (TDD) users call the Minnesota Relay Service at 1.800.627.3529 and ask to be
connected to MSRS at 651.296.2761..
Information About You
Enter your basic information - legal name, MSRS account ID or Social
Security number, contact information, marital status, and your spouse’s
information.
Private data requested on this form will be used by MSRS to process
your request. You are no legally required to provide the data requested.
However, we may not be able to process your request without sufficient
information. Your private data will not be shared with an unauthorized
person without written consent except as authorized by federal or state
law or a court order.
Your Retirement
Indicate the last day you worked for the employer who sponsored your
Minnesota public retirement plan and the date you want your retirement
benefit to begin. You must be terminated prior to the benefit start date.
The retirement benefit start date must be after your last day on payroll.
EXAMPLE:
Your last day worked is January 20 + 2 days of vacation pay to keep
you on the payroll.
Last day on payroll = January 22
Retirement benefit start date = January 23 or after
Your retirement benefit start date
Use this table as a guide to determine your benefit start date options.
Income Tax Withholding
Pension benefit payments are taxable income. You have the option to
provide instructions to MSRS for federal and Minnesota state tax
withholding. If no instructions are provided, the default withholding
will apply.
MSRS staff members are unable to provide advice regarding tax
withholding. You are encouraged to consult a tax advisor to determine
your appropriate income tax withholding.
Federal Taxes
Complete a Form W-4P Withholding Certificate to provide MSRS with
instructions for federal tax withholding. If you do not submit a Form W-4P
to MSRS, federal law requires that we withhold taxes from your monthly
pension benefit assuming your filing status is single and no
adjustments (regardless of your actual marital status).
You can elect not to have federal taxes withheld from your payments. See
the Form W-4P Withholding Certificate instructions.
Caution: If you have too little tax withheld, you will generally owe the IRS
when you file your tax return and may owe a penalty. If too much tax is
withheld, you will generally be due a refund when you file your tax return.
For more detail, go to www.irs.gov for Form W-4P Withholding Certificate
for Pension or Annuity Payments.
Minnesota State Taxes
The Minnesota Department of Revenue requires that we withhold state
taxes from your monthly pension benefit (Minnesota residents only. We
cannot withhold taxes for other states).
Complete a Form W-4MNP, Minnesota Withholding Certificate to request
the default rate of 6.25%, no withholding, or a specified percentage or
dollar amount. Submit the form to MSRS with your application for a
retirement benefit. If you do not submit a W-4MNP to MSRS, a flat 6.25%
withholding rate will apply.
For more detail, see www.revenue.state.mn.us/withholding-annuities-
and-pensions.
Notarized Signature(s)
The application must be signed by you and your spouse in the precense
of a notary. Only the original application with signature and notary will be
processed. A faxed or emailed copy is not accceptable. The date this form
is signed must match the date your signature is notarized.
Spousal notarized signature
If you are married, your spouse must agree with the retirement option you
elected and the named survivor. Minnesota law requires that you provide
at least a 50% Joint-and-Survivor benefit option for your spouse unless
they waive survivor coverage in Section 6.
Your notarized signature
Your signature acknowledges that you have read and agree to the terms
of all elections.
Minnesota Retired State Employees Association
(MRSEA)
We provide MRSEA with new retiree’s name and address. You can
request that we not share your information. To learn more about this
non-profit organization, visit www.mrsea.org.
I currently work for
the employer that
sponsored my MSRS
retirement plan
I no longer work for
the employer that
sponsored my MSRS
retirement plan and left
that employment no
more than 180 days ago.
I no longer work for
the employer that
sponsored my MSRS
retirement plan and left
that employment more
than 180 days ago.
• Retirement benefit start date can be anytime
after your last day on payroll.
• If benefit start date is left blank, your benefit will
begin the day after your last day on payroll.
• Retirement benefit start date can be anytime
between your last day on payroll and up to 60
days after the date we receive this application.
• If benefit start date is left blank, we will start the
benefit on the date that will provide the highest
overall benefit to you.
• Retirement benefit start date can be up to 60
days prior to the date we receive this application.
• If benefit start date is left blank, we will start the
benefit on the date that will provide the highest
overall benefit to you.
Guide to Apply for a Monthly Retirement Benefit
Page 7 of 7
GERP App /MSRS/10.11.23
Single-Life
100%
Joint-and-Survivor
75%
Joint-and-Survivor
50%
Joint-and-Survivor
Life Income
15-Year Certain
Why choose
this option
Benefit paid for
your lifetime
Who can you
name as a
survivor
What happens
to benefit upon
your death
What happens
if named
survivor
predeceases
you
Retirement Benefit Options
Provides you the
highest monthly
benefit compared to
other options.
Provides maximum
survivor coverage,
but reduces your
monthly payment.
Provides some
survivor coverage
but reduces your
monthly payment.
Provides some
survivor coverage,
but reduces your
monthly payment.
Typically used to
preserve assets for
your children or other
family members.
Anyone, but typically a spouse. Your monthly benefit is
reduced in order to provide coverage to a survivor upon
your death. The reduction is based on the age difference
between you and your survivor. The younger the survivor
the greater your monthly benefit is reduced.
The age of your survivor may limit you from choosing this
option. Contact MSRS for details.
State law requires that
you provide at least
a 50% Joint-and-
Survivor option for
your spouse unless
they waive survivor
coverage.
Monthly payments
end. Any remaining
account balance is
paid to your beneficiary.
Survivor will receive
monthly payment
equal to your
payments for
their lifetime.
Survivor will receive
monthly payment
that is 75% of your
payments for their
lifetime.
Survivor will receive
monthly payment
that is 50% of your
payments for their
lifetime.
If you received
payments for:
• 15 years or more,
payments will end.
• Less than 15 years,
your survivor will
receive payments
for balance of
15-year term.
Note: If both you
and your survivor die
before the 15-year
term, any remaining
balance is paid to
your estate.
Monthly benefit will increase (“bounce back”) to the single-life benefit amount
after MSRS has been notified and receives the death certificate..
Has no impact on your
benefit payment.
You can name
another survivor.
N/A
N/A
Yes
Anyone.
Yes
Yes
Yes Yes
This chart is a comparison of the retirement benefit options. Please review your options carefully before completing Sections 3 and 4 of
this application.
