BENEFIT ESTIMATE REQUEST PUBLIC EMPLOYEES …

1 State of West Virginia Consolidated PUBLIC retirement Board Internet Form (Signature in Blue Ink Only) 4101 MacCorkle Avenue SE, Charleston, West Virginia 25304-1636 Telephone: 304-558-3570 or 800-654-4406 Fax: 304-558-1394 BENEFIT ESTIMATE REQUEST PUBLIC EMPLOYEES retirement SYSTEM (PERS) Please complete and return the following information to this office to obtain an ESTIMATE of your retirement benefits. Upon receipt of this information, the Consolidated PUBLIC retirement Board will prepare an ESTIMATE of your retirement benefits. Important Notice: An ESTIMATE is merely advisory in nature and is not binding upon either the retirement Board or the Member. Name:_____ SSN (Last 4 digits only):_____ Address: _____ Date of Birth: _____ City/State:_____ Zip Code:_____ Home Phone#:_____ Current Employer:_____ Work Phone #:_____ I anticipate my last day of work will be:_____(Date must be provided in order to calculate ESTIMATE ) Beneficiary Name:_____ Beneficiary Date of Birth:_____ Relationship:_____ Beneficiary SSN (Last 4 Digits Only):_____ Have you purchased or reinstated service within the last year?

2 Yes No Do you have military service? Yes No If yes, please enclose a copy of your DD214 form. Has your military service been credited in another retirement system administered by CPRB? Yes No Are you currently serving as an elected or appointed PUBLIC official? Yes No **A member who is participating in the PUBLIC EMPLOYEES retirement System (PERS) as an elected or appointed PUBLIC official may not retire from his or her elected or appointed position, commence to receive an annuity from the system, and then be reappointed or reelected to the same position unless and until a continuous twelve-month period has passed since his or her retirement from the position. If you are interested in converting sick/annual leave for service credit, list total number of accrued unused annual and/or sick leave days **If your retirement is deferred, it is important that you contact a PERS retirement Advisor prior to termination of employment to determine whether or not accumulated sick/annual leave is eligible to be used toward an increase in retirement benefits.

3 Are you a retired police officer or firefighter receiving a pension from any retirement system? Yes No If yes, list the retirement system from which you are retired?_____ NOTES: This ESTIMATE REQUEST form may not be used to effect a change of beneficiaries. In preparing for retirement , keep in mind that the processing time for computing a retirement annuity will take approximately six to eight weeks after your effective date of retirement . Effective date of retirement is dependent upon meeting retirement eligibility, last day of employment and receipt of retirement application. Signature:_____ Date:_____ COMMENTS:_____