Retirement Allowance Estimate Request
888 CalPERS (or 888-225-7377) • TTY: (877) 249-7442
This is a request for an estimate of your potential CalPERS retirement benefit amounts. You must be within one year
of your anticipated retirement date to use this form. You are limited to two estimate requests within a 12-month period.
Section 1 Information About You
Enter the address we
Todd W Parsnick 072627285
Your Name (First Name, Middle Initial, Last Name) Social Security Number or CalPERS ID
have on file for you.
If you need to update
06/25/1969 5103845670
( ) ( )
Birth Date (mm/dd/yyyy) Daytime Phone Alternate Phone
your address, see the
back of this form 2063 Love Creek Rd
Address
for instructions.
Arnold CA 95223
City State ZIP
Section 2 Your Retirement Information
You can only select Choose one type: c Service Retirement c Disability Retirement c Industrial Disability Retirement
one type of retirement
My projected retirement date is: 07/01/2023
estimate per form. Date Required (mm/dd/yyyy)
University of California San Francisco APPLICATIONS PRG SUPV 2
Employer Position Title
To include your unused sick leave and/or educational leave in your estimate, enter the number of hours you’ll
have as of your projected retirement date. See the back of this form for eligibility requirements.
1689.67
Sick Leave Hours Educational Leave Hours
What is a survivor vs. a Will you have an eligible survivor on your projected retirement date? c Yes c No
beneficiary? See the back
How many beneficiaries do you want to include in your estimate?
of this form for details and c None
a complete description of c One (Complete the information in the space provided below.)
the available retirement
payment options. Name of Beneficiary Relationship to You Birth Date (mm/dd/yyyy)
c One or more and with a specific dollar or specific percentage amount to each beneficiary.
(Complete the information in the spaces provided below.)
Birth Date (mm/dd/yyyy) Dollar or Percent of Benefit Birth Date (mm/dd/yyyy) Dollar or Percent of Benefit
Birth Date (mm/dd/yyyy) Dollar or Percent of Benefit Birth Date (mm/dd/yyyy) Dollar or Percent of Benefit
Section 3 Advanced Estimate Scenarios
See the back of this If you are a member of a defined benefit plan with another California public retirement system and want
form for information us to use your final compensation with the other system in your estimate, complete the information below.
regarding the Advanced University of California Retirement Plan (UCRP) 177,278 per yr
Name of Reciprocal System Estimated Final Compensation Amount
Estimate Scenarios.
If you want to include temporary annuity in your retirement estimate, select one of the choices below.
c I became a member prior to January 1, 2002, and elect to receive temporary annuity until
age in the amount of $ per month.
(59 1/2 or whole age 60 to 68) Dollars
c I became a member on January 1, 2002, or later and have CalPERS service coordinated with Social
Security. I elect to receive temporary annuity until age in the amount of $
(62 to 70) Dollars
per month.
Mail to: CalPERS Retirement Benefit Services Division • P.O. Box 942711, Sacramento, California 94229-2711
PERS-BSD-470 (12/21) Page 1 of 1
Section 1 Information About You
• If you are an active CalPERS member, contact your personnel office and ask them to update your mailing address with us.
• If you are an inactive CalPERS member, update your address at my.calpers.ca.gov or call us toll free at 888 CalPERS
(or 888-225-7377).
Section 2 Your Retirement Information
Retirement Date - Your retirement date can be no earlier than your last day on payroll. If it has been more than nine months
since you left employment, the date you enter cannot be earlier than the first day of the month you submit this form.
Unused Sick Leave/Educational Leave - Your last employer must contract to provide this benefit, and you must retire within
120 days of leaving employment for any unused sick and/or educational leave to be included in your actual retirement benefit.
What is a survivor? - A survivor receives a monthly benefit regardless of the retirement payment you choose. We only
include this in your retirement estimate if your employer contracts to provide this benefit. A survivor is defined by law as:
• a spouse or registered domestic partner who was married or registered to you for at least one year before your service
retirement date and continuously until your death. (For disability or industrial disability retirement, these conditions
must be met on or before the effective date of your disability or industrial disability retirement.)
• natural or adopted unmarried children under age 18.
• an unmarried child who was disabled prior to age 18 and whose disability continues without interruption until
the disability ends or until marriage.
• qualifying financially dependent parents, if none of the above.
What is a beneficiary? - A beneficiary is any person you choose to receive either a one-time lump-sum payment
or ongoing monthly benefit upon your death.
Retirement Options - When you retire, you will choose one of the following retirement options and name a beneficiary.
• Unmodified Allowance - Provides the highest monthly allowance paid for life. There is no continuing monthly benefit
to a beneficiary and no return of unused member contributions upon your death.
• Return of Remaining Contributions Option 1 - Provides a lump-sum payout of any remaining member contributions
in your account to one or more beneficiaries upon your death.
• 100 Percent Beneficiary Option 2 - Provides 100 percent of the option portion of your ongoing monthly benefit to your
named beneficiary upon your death. Upon both your deaths a lump-sum payout of any remaining member contributions
in your account will be paid to one or more named secondary beneficiaries.
• 100 Percent Beneficiary Option 2 with Benefit Allowance Increase - Provides 100 percent of the option portion of
your monthly benefit to your named beneficiary upon your death. If your beneficiary dies before you, or if you have another
qualifying event, your benefit will increase to the Unmodified Allowance.
• 50 Percent Beneficiary Option 3 - Provides 50 percent of the option portion of your ongoing monthly benefit to your
named beneficiary upon your death. Upon both your deaths, a lump-sum payout of any remaining member contributions
in your account will be paid to one or more named secondary beneficiaries.
• 50 Percent Beneficiary Option 3 with Benefit Allowance Increase - Provides 50 percent of the option portion of your
ongoing monthly benefit to your named beneficiary upon your death. If your beneficiary dies before you, or you have
another qualifying event, your benefit will increase to the Unmodified Allowance.
• Flexible Beneficiary Option 4 - Provides an ongoing monthly benefit of a specific percentage or specific dollar amount
of your retirement benefit to one or more named beneficiaries upon your death.
Section 3 Advanced Estimate Scenarios
Reciprocity
• Enter the name of the other California public retirement system you are a member of.
• Enter your highest average annual compensation for any consecutive 12- or 36-month period of employment
with the other retirement system.
• To be eligible for full reciprocal benefits, such as final compensation exchange, you must retire concurrently.
• Refer to the publication When You Change Retirement Systems (PUB 16) for detailed information.
Temporary Annuity
• This benefit is only available for a service retirement.
• Enter the amount you want to receive and to what age depending on your CalPERS membership date.
• If your membership is on or after January 1, 2002, your temporary annuity amount cannot exceed your estimated Social
Security benefit. This benefit is not free. Refer to the publication Temporary Annuity (PUB 13) for detailed information.
PERS-BSD-470 (12/21)
Privacy Notice
The privacy of personal information is of the utmost importance to CalPERS.
The following information is provided to you in compliance with the Information
Practices Act of 1977 and the Federal Privacy Act of 1974.
Information Purpose Social Security numbers are used for the
The information requested is collected pursuant following purposes:
to the Government Code (sections 20000 et seq.) 1. Enrollee identification
and will be used for administration of Board 2. Payroll deduction/state contributions
duties under the Retirement Law, the Social 3. Billing of contracting agencies for employee/
Security Act, and the Public Employees’ Medical employer contributions
and Hospital Care Act, as the case may be. 4. Reports to CalPERS and other state agencies
Submission of the requested information is 5. Coordination of benefits among carriers
mandatory. Failure to comply may result in 6. Resolving member appeals, complaints,
CalPERS being unable to perform its functions or grievances with health plan carriers
regarding your status.
Information Disclosure
Please do not include information that is Portions of this information may be transferred
not requested. to other state agencies (such as your employer),
physicians, and insurance carriers, but only
Social Security Numbers in strict accordance with current statutes
Social Security numbers are collected on a regarding confidentiality.
mandatory and voluntary basis. If this is CalPERS’
first request for disclosure of your Social Security Your Rights
number, then disclosure is mandatory. If your You have the right to review your membership
Social Security number has already been provided, files maintained by the System. For questions
disclosure is voluntary. Due to the use of Social about this notice, our Privacy Policy, or your rights,
Security numbers by other agencies for please write to the CalPERS Privacy Officer at
identification purposes, we may be unable to 400 Q Street, Sacramento, CA 95811 or call us
verify eligibility for benefits without the number. at 888 CalPERS (or 888-225-7377).
May 2016
