RETIREMENT CHECKLIST

(Rev. 02-2022) RETIREMENT CHECKLIST RETIREMENT FORMS Required for Benefit Payment SFN # APPLICATION FOR MONTHLY RETIREMENT BENEFITS FOR DEFINED BENEFIT* APPLICATION FOR PERIODIC PAYMENTS FOR DEFINED CONTRIBUTION 2562 or 59045 LEGIBLE PHOTOCOPIES OF BIRTH CERTIFICATE, SPOUSE S BIRTH CERTIFICATE & MARRIAGE CERTIFICATE AUTHORIZATION FOR DIRECT DEPOSIT FOR ANNUITY PAYMENTS 18379 DESIGNATION OF BENEFICIARY FOR THE GROUP RETIREMENT 2560 WITHHOLDING ALLOWANCE ELECTION FOR PENSION PAYMENTS 51506 RETIREMENT FORMS Optional APPLICATION FOR THE PARTIAL LUMP SUM OPTION DEFINED BENEFIT (If at Normal RETIREMENT Age) 54373 APPLICATION FOR THE GRADUATED BENFIT OPTION DEFINED BENEFIT (If at Normal RETIREMENT Age) 59596 CONVERSION OF UNUSED SICK LEAVE APPLICATION DEFINED BENEFIT* (complete only if buying unused sick leave for RETIREMENT service credit) 58358 INSURANCE FORMS Required SFN # Health - Continuation of Coverage CONTINUATION OF GROUP INSURANCE COVERAGE (COBRA) (Complete only for family members electing individual coverage if currently covered on NDPERS Dakota Plan or HDHP plan) 14120 retiree CONTINUATION OF GROUP HEALTH INSURANCE COVERAGE (COBRA) (Complete if currently covered on NDPERS Dakota Plan or HDHP Plan) 53799 Health - Medicare Coverage retiree HEALTH INSURANCE APPLICATION WITH MEDICARE (If either you or a dependent is over)

MEDICARE PRESCRIPTION DRUG PLAN (PDP) INDIVIDUAL ENROLLMENT FORM (One required for each member that will be on the Dakota Retiree Plan and . cannot . ... RETIREE VISION\DENTAL INSURANCE ENROLLMENT, CHANGE, OR CANCEL (Complete if continuing, enrolling, or canceling coverage) 53504 ... (Rev. 11-2019) Page 2 .

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