Future Retirement Information Request Form

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Please correct the field(s) marked in red below:

Please complete all applicable information below and submit. Upon receipt and if you are eligible for retiree benefits, a customized Retiree Health Benefits Package with additional information will be mailed directly to you, within 30 days of your retirement effective date (which is first of the month following your last day worked).

Contact Information:

*

Contact Information:

First Name

Last Name

Employee ID

Street Address

City

State

Zip Code

Home Phone Numberext.

Cell Phone Numberext.

Which retirement system are you retiring from?*

ASRS

**PSPRS

**If you selected PSPRS, are you a Sworn PD or FD Employee?

Yes

No

Retirement Date Information:

What is your last official day with the City of Mesa?

What is your Retirement effective date?

How many full years of service will you have with the City of Mesa?

If applicable, please complete the following information

Is your spouse an active employee or retired from the City of Mesa? If so, please provide the name and employee ID number of your spouse:

Spouse Full Name

Spouse Employee ID

Is your spouse receiving a pension from ASRS or PSPRS? Is so, please designate the retirement system:

ASRS

PSPRS

Will you or your spouse be eligible for Medicare at the time of your retirement? If so, give the name of the person and the effective date of coverage:

Name of person(s)

Effective date(s) of coverage:

Comments

To receive a copy of your submission, please fill out your email address below and submit.
Email Address

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Code: