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 85: Electronic Funds Transfer (Direct Deposit) Sign-Up
• SRA Form 766.11: Maryland State Tax Withholding Request
• IRS Form W-4P: Withholding Certificate for Pension or Annuity Payments

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 455-2B, Addendum to Application for Retirement/Notice of Separation: Resolution of Financial Obligations to MCPS  
• MCPS Form 455-5: Designation of Beneficiary  
• Aetna Direct Deposit form  
• MCPS Form 281-50, MCPS Employees' Retirement/Pension System Maryland State Withholding Request  
• MCPS Form 455-22R: Retiree Benefit Plan Enrollment  
• MCPS Form 480-4: Notice of Termination/Retirement
• IRS Form W-4P: Withholding Certificate for Periodic Pension or Annuity Payments

Additional Related Forms and Information

• MCPS Form 445-1B: Change in Personal Information
• MCPS Form 455-26: Application for Lump Sum (De minimis) Retirement Distribution
• MCPS Form 455-28, 403(b) Leave Payout Contribution Agreement
• MCPS Form 455-29, 457(b) Leave Payout Contribution Agreement
• MCPS Form 455-4, Request for Refund of MCPS Prepaid Benefits
• Leave Payout Frequently Asked Questions
• IRS Form W-4R: Withholding Certificate for Nonperiodic Payments and Eligible Rollover Distributions
• Employee/Covered Dependent Enrollment in Medicare Part B (If you are enrolled in Medicare Part A contact your local Social Security office before you enroll online.
• Form CMS-L564E: Request for Employment Informationemail ersc@mcpsmd.org to request employment verification. Completed form will be sent via email to your mcpsmd.org email account)
• Form CMS-40B: Application for Enrollment in Medicare Part B (Medical Insurance)

Social Security Administrative (SSA) offices are currently closed. See instructions to enroll online in Medicare Part B.

Once you apply for Medicare Part B, please visit Medicare.gov, Create an account by establishing a username and password. This will allow you to track the progress of your Medicare Part B application at SSA and provide you with access to the PDF version of your Medicare Part B card. Please email the PDF version of your Medicare Part B card to ERSC

• 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