Title *
-Select-
Mr.
Ms.
First Name *
i.e. Jane or John
Middle Name
i.e. Anne or James
Last Name *
i.e. Doe
Suffix
i.e. Jr., Sr., I, II, or III
Date of Birth * Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022
(Please provide copy of your birth certificate)
Social Security Number *
Country of Residence *
United States
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia, Plurinational State of
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Côte d’Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Figi
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People’s Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People’s Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia, Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russia
Rwanda
Samoa
San Marino
São Tomé and Príncipe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
St. Barthélemy
St. Helena
St. Kitts and Nevis
St. Lucia
St. Maarten
St. Martin
St. Pierre and Miquelon
St. Vincent and the Grenadines
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syira
Taiwan
Tajikistan
Tanzania
Thailand
Timor Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
US Virgin Islands
Uzbekistan
Vanuatu
Vatican City State
Venezuela
Vietnam
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Title *
-Select-
Mr.
Ms.
First Name *
i.e. Jane or John
Middle Name
i.e. Anne or James
Last Name *
i.e. Doe
Suffix
i.e. Jr. , Sr. , I , II , or III
Date of Birth * Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022
(Please provide copy of your birth certificate)
Social Security Number *
Country of Residence *
United States
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia, Plurinational State of
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Côte d’Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Figi
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People’s Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People’s Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia, Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russia
Rwanda
Samoa
San Marino
São Tomé and Príncipe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
St. Barthélemy
St. Helena
St. Kitts and Nevis
St. Lucia
St. Maarten
St. Martin
St. Pierre and Miquelon
St. Vincent and the Grenadines
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syira
Taiwan
Tajikistan
Tanzania
Thailand
Timor Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
US Virgin Islands
Uzbekistan
Vanuatu
Vatican City State
Venezuela
Vietnam
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
OPTION ELECTION *
Please indicate if the Participant will be required to elect an option upon retirement for the benefit of the Alternate Payee.
No Restriction
Special Joint Allowance : This option provides the Participant with a reduced lifetime benefit based on the Participant’s and the Alternate Payee’s dates of birth. The continuance payable to the Alternate Payee after the Participant’s date of death is the marital share identified above. If the Alternate Payee dies before the Participant, all payments stop at the Participant’s death. The Participant can only designate one beneficiary and the beneficiary cannot be changed.
Joint Allowance — Full : This option provides the Participant with a reduced lifetime benefit based on the Participant’s and the Alternate Payee’s dates of birth. If the Participant dies, the Alternate Payee will receive the Participant’s total monthly benefit for the rest of his/her life. If the Alternate Payee dies before the Participant, all payments will stop at the Participant’s death. The Participant can only designate one beneficiary and the beneficiary cannot be changed.
Joint Allowance — Half : This option provides the Participant with a reduced lifetime benefit based on the Participant’s and the Alternate Payee’s dates of birth. If the Participant dies, the Alternate Payee will receive one-half of the Participant’s monthly benefit for the rest of his/her life. If the Alternate Payee dies before the Participant, all payments will stop at the Participant’s death. The Participant can only designate one beneficiary and the beneficiary cannot be changed.
Joint Allowance — Partial 75% : This option provides the Participant with a reduced lifetime benefit based on the Participant’s and the Alternate Payee’s dates of birth. The Participant must elect the continuance of 75 percent of the retirement benefit payable to the Alternate Payee. If the Participant dies, the Alternate Payee will receive 75 percent of the amount the Participant had been receiving for the rest of his/her life. If the Alternate Payee dies before the Participant, all payments stop at the Participant’s death. The Participant can only designate one beneficiary and the beneficiary cannot be changed.
Joint Allowance — Partial 50% : This option provides the Participant with a reduced lifetime benefit based on the Participant’s and the Alternate Payee’s dates of birth. The Participant must elect the continuance of 50 percent of the retirement benefit payable to the Alternate Payee. If the Participant dies, the Alternate Payee will receive 50 percent of the amount the Participant had been receiving for the rest of his/her life. If the Alternate Payee dies before the Participant, all payments stop at the Participant’s death. The Participant can only designate one beneficiary and the beneficiary cannot be changed.
Joint Allowance — Partial 25% : This option provides the Participant with a reduced lifetime benefit based on the Participant’s and the Alternate Payee’s dates of birth. The Participant must elect the continuance of 25 percent of the retirement benefit payable to the Alternate Payee. If the Participant dies, the Alternate Payee will receive 25 percent of the amount the Participant had been receiving for the rest of his/her life. If the Alternate Payee dies before the Participant, all payments stop at the Participant’s death. The Participant can only designate one beneficiary and the beneficiary cannot be changed.
Five Year Certain : This option provides the Participant with a reduced lifetime benefit and the additional guarantee that, if he/she lives for less than five years after retirement, payments in the same amount he/she was receiving (without COLA ) will be made to the beneficiary(ies) for the balance of the five-year period. If the Participant lives more than five years after retirement, he/she will continue to receive payments for his/her lifetime, but no payments will be made to any beneficiary(ies) or estate when the Participant dies. The beneficiary(ies) may be changed at any time. If the beneficiary(ies) dies within the five-year period and the Participant dies without naming a new beneficiary(ies), any amount payable will be paid to the Participant’s estate.
Alternate Payee is sole beneficiary of the Five Year Certain Option.
Alternate Payee is entitled to a prorate share of the Five Year Certain Option.
Ten Year Certain : This option provides the Participant with a reduced lifetime benefit and the additional guarantee that, if he/she lives for less than ten years after retirement, payments in the same amount he/she was receiving (without COLA) will be made to the beneficiary(ies) for the balance of the ten-year period. If the Participant lives more than ten years after retirement, he/she will continue to receive payments for his/her lifetime, but no payments will be made to any beneficiary(ies) or estate when the Participant dies. The beneficiary(ies) may be changed at any time. If the beneficiary(ies) dies within the ten-year period and the Participant dies without naming a new beneficiary(ies), any amount payable will be paid to the Participant’s estate.
Alternate Payee is sole beneficiary of the Ten Year Certain Option.
Alternate Payee is entitled to a prorate share of the Ten Year Certain Option.