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MCPS Core and Supplemental Plan
Retirement Application Forms

Retirement Forms Packet*

 MCPS Core Plan Forms Packet 
 MCPS Core Plan Sample Forms Packet  

Individual Retirement Forms

Members of the MCPS core and supplemental plan will need to download and complete the following forms:  

MCPS Form 455-2, Application for Retirement 

MCPS Form 455-2B, Addendum to Application for Retirement/Notice of Separation: Resolution of Financial Obligations to MCPS

MCPS Form 455-5, Designation of Beneficiary 
Aetna Form GP 82519: Aetna Electronic Funds Transfer Authorization (Direct Deposit)  

MCPS Form 455-22R, Retiree Benefit Plan Enrollment for New Retirees  

MCPS Form 480-4, Notice of Termination/Retirement  

MCPS Form 281-50, MCPS Employees' Retirement/Pension System Maryland State Withholding Request 

IRS Form W-4P: Withholding Certificate for Periodic Pension or Annuity Payments

Additional Related Forms and Information

MCPS Form 445-1B, Change in Personal Information

MCPS Form 455-26, Application for Lump Sum (De minimis) Retirement Distribution

MCPS Form 455-28, 403(b) Leave Payout Contribution Agreement

MCPS Form 455-29, 457(b) Leave Payout Contribution Agreement

MCPS Form 455-4, Request for Refund of MCPS Prepaid Benefits

IRS Form W-4R: Withholding Certificate for Nonperiodic Payments and Eligible Rollover Distributions

Leave Payout Frequently Asked Questions

Employee/Covered Dependent Enrollment in Medicare Part B (If you are enrolled in Medicare Part A contact your local Social Security Office before you enroll online)

•  Form CMS-L564E: Request for Employment Information(email ersc@mcpsmd.org to request employment verification. Completed form will be sent via email to your mcpsmd.org email account)
•  Form CMS-40B: Application for Enrollment in Medicare Part B (Medical Insurance)

Social Security Administrative offices are currently closed. The link below provides instructions to enroll online in Medicare Part B

https://www.ssa.gov/pubs/EN-05-10531.pdf

Once you apply for Medicare part B, please visit www.Medicare.gov,  register and create a username and password. This will allow you to track the progress of Medicare Part B application at Social Security and provide you with access to the PDF version of your Medicare Part B card. Please email the pdf version of your Medicare Part B card to the ERSCmailbox(ersc@mcpsmd.org)

Out-of-State Income Tax Withholding Form

Submit all forms to ERSC at least one month prior to your scheduled retirement.

Additional Resources

Understanding Your Retirement (PDF)
This booklet will guide you through the retirement process and assist you in understanding your retirement benefit.

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