Complete the form below and an MCERA representative will contact you to schedule an appointment.

1

First Name:

 *

First Name:

2

Middle Name or Initial:

Middle Name or Initial:

3

Last Name:

 *

Last Name:

4

Date of Birth:

 *

Date of Birth:

5

Email Address:

 *

Email Address:

6

Current Mailing Address:

Current Mailing Address:

7

Current Marital or State-Registered Domestic Partnership Status:

 *

Current Marital or State-Registered Domestic Partnership Status:

Single

Married or Partnered

Spouse or Domestic Partner Deceased

8

Have you divorced or dissolved your marriage or state-registered domestic partnership during your MCERA membership?

Have you divorced or dissolved your marriage or state-registered domestic partnership during your MCERA membership?

Yes

No

9

Reason for requesting an appointment:

Reason for requesting an appointment:

Submit Retirement Application

Retirement Benefit Estimate

Disability Retirement

Service Purchase Estimate

Other If other, type text here.

10

What type of appointment would you prefer?

What type of appointment would you prefer?

Office

Phone

Email Estimate

Mail Estimate

11

Retirement Benefit Estimates
Complete this section for an estimate of your retirement allowance. You may request up to three retirement dates for comparison:

Retirement Benefit Estimates Complete this section for an estimate of your retirement allowance. You may request up to three retirement dates for comparison:

Estimate Date 1

Estimate Date 2

Estimate Date 3

12

If you have established reciprocity between MCERA and another retirement system, please provide the following information.

If you have established reciprocity between MCERA and another retirement system, please provide the following information.

Name of Reciprocal System:

Monthly Salary from Reciprocal System:

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

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