About this Form
Form number: 455-22
Audience: MCPS Retirees
Last revised: October 2017
This version of Form 455-22 is to be used ONLY for benefit plan year 2018. If you need to make a change to your benefits for the remainder of the 2017 plan year, please contact the Employee and Retiree Service Center at 301-517-8100 to request the 2017 version of the form.
INSTRUCTIONS: All new retirees must make a selection in each category. Complete, sign electronically or manually on both sides of this form, and return to the Employee and Retiree Service Center (ERSC). You may fax the signed form to 301-279-3651 or 301-279-3642, or e-mail a PDF of the signed form to ERSC@mcpsmd.org. This form must be signed at the bottom of pages 1 and 2. Please do not mail copies to ERSC once you have faxed or e-mailed the enrollment form. A confirmation of your requested change(s) will be sent to you. Unsigned forms will be returned to you and become your responsibility to resubmit to ERSC by the appropriate deadline.
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