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Employee and Retiree Service Center → Employees → Retirement planning → State core and MCPS supplemental plan application forms

State Core and MCPS Supplemental Plan
Retirement Application Forms

Retirement Forms Packet*

State Core Plan Forms Packet
State Core Plan Sample Forms Packet

Individual Retirement Forms 

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

SRA Form 13-23: Application for Service or Disability Retirement
SRA Form 4: Designation of Beneficiary
SRA Form 766: Federal and Maryland State Tax Withholding
SRA Form 85: Electronic Funds Transfer (Direct Deposit) Sign-Up
SRA Form 127: Reemployment After Retirement  

In addition, members of the State core plan will need to download and complete the following forms to receive their MCPS supplemental plan benefit:

MCPS Form 455-2: Application for Retirement
MCPS Form 455-5: Designation of Beneficiary
Aetna Direct Deposit form
MCPS Form 455-22: Retiree Benefit Plan Enrollment 
MCPS Form 480-4: Notice of Termination/Retirement

Additional Related Forms and Information

MCPS Form 445-1: Change in Personal Information

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

MCPS Leave Payout Contribution
403(b) Leave Payout Form

MCPS Leave Payout Contribution 
457(b) Leave Payout Form

Leave Payout Frequently Asked Questions

Employee/Covered Dependent Enrollment in Medicare Part B

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.

Back to Retirement Planning     

*includes all individual retirement forms in one easy-to-print document
 

Montgomery County Public Schools

Contact MCPS

Call: 301-309-6277 | Spanish Hotline: 301-230-3073
E-mail: ASKMCPS@mcpsmd.org

Contact Employee & Retiree Services Center

Call: 301-517-8100 | E-mail: ersc@mcpsmd.org

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