Retirement Forms & Publications (PDF format)

Plan Guides and Summaries Insurance (retirees)
Guides to Retiring Direct Deposit Forms (retirees)
401 (k) MAP and 457 RSVP Termination Distribution Forms
(retirees/termination)
175/185 Supplemental Share
Plan (Fire & Police)
Social Security Notice
Deferred Retirement Option
Plan (DROP)
Temporary Employees Information
BuyBack Program  

Frequently Used Forms

Name/Address Change Form
Retirement Benefits Estimate Request (DryRun) Form
Beneficiary Designation Form
Beneficiary Designation for Temporary Employee Form
Retirement Notification and Instructions Form
W4P Withholding for Pension or Annuity Form

Plan Guides & Summaries

The Plan Guide is the ultimate source of comprehensive information about City retirement benefits. The plan guide provides detailed information about retirement benefits including:

  • General Plan Information
  • Eligibility and Membership
  • When You Can Retire
  • Your Benefit Amount
  • How Your Benefit is Paid
  • Benefits Payable Upon Your Death
  • Termination of Employment

Plan Guide - General Employees
Plan Guide - Firefighters
Plan Guide - Police Officers
Plan Highlights for Firefighters
Plan Highlights for New General Employees (Part D)
Plan Highlights for Police Officers
Pre-Retirement Survivor Annuity Information
Qualified Domestic Relations and Income Deduction Orders (QDRO/IDO)

Guides to Retiring

Guide to Retiring - General Employees
Guide to Retiring - Police Officers & Firefighters
Guide to Retiring for Vested Employees
Retirement Notification and Instructions Form
Payment Options for 401(k) MAP
Payment Options for 457 RSVP, 175/185 Supplemental Share, and DROP

401 (k) MAP and 457 RSVP

MAP vs RSVP Comparison Chart
MAP/RSVP Contribution Limits Info Sheet
401 (k) MAP Contribution Change Form: General Employees
401 (k) MAP Contribution Change Form: Police and Fire
401 (k) MAP Enrollment Form
401 (k) MAP Options at Retirement
457 RSVP Contribution Change Form
457 RSVP Enrollment Form
457 RSVP Options at Retirement
401(k) Hardship Withdrawal Guidance

175/185 Supplemental Share Plan (Firefighters and Police Officers)

175 Supplemental Share Plan for Firefighters Information Sheet
185 Supplemental Share Plan for Police Officers Information Sheet

Deferred Retirement Option Plan (DROP)

DROP Enrollment Instructions and Form
DROP-to-Retirement Notification and Instructions Form
DROP Information Sheet For General Employees
DROP Information Sheet for Firefighters
DROP Information Sheet for Police Officers
DROP Begin and End Dates
DROP Account Value Estimator (to estimated amount that can be accumulated)

BuyBack Program

175 Firefighter Buyback Rollover Form
185 Police Buyback Rollover Form
401 (k) MAP Buyback Rollover Form
457 RSVP Buyback Rollover Form
Out of City Public Service Verification Form

Insurance

2013 Retiree Insurance Changes (beginning with January Pension Check)

FL Blue/CHP Rates and Benefits

Health Care Premiums for FL Blue/CHP
Health Care Premiums for FL Blue/CHP With Rates For Overage Dependents
Changes to Coverage Outside of Open Enrollment: FL Blue/CHP
Discontinue Retiree Health Form

FL Blue

FL Blue Enrollment Form
FL Blue Status Change Form
FL Blue Dependent Verification Form
FL Blue PrimeMail Pharmacy Mail Order Form
FL Blue Schedule of Benefits & Prescription Program
FL Blue Find A Provider
FL Blue HIPAA Authorization Form
FL Blue Notice of Special Enrollment Rights
Domestic Partner Information
Domestic Partnership For Retirees Affidavit
Domestic Partnership Termination Affidavit
FL Blue Prior/Concurrent Coverage Affidavit
FL Blue Prior/Concurrent Coverage Info
FL Blue Prior Authorization
FL Blue Summary of Benefits

CHP

CHP Enrollment Form
CHP Dependent Eligibility Verification Form
CHP Member Status Change Form
CHP Caremark Mail Order Form
CHP Understanding How CHP Works
CHP Schedule of Benefits
CHP Physician List
CHP Away From Home Brochure
CHP Caremark Brochure
CHP Connect (Access to Online Medical Records)
CHP Overage Dependent Enrollment Form
CHP Personal Health Assessment
CHP Prescription Program
CHP Summary of Benefits

CHP Medicare

CHP Medicare Enrollment Form
CHP Medicare Made Easy Brochure for Retiree Advantage
CHP Medicare Schedule of Benefits for Retiee Advantage Copayments
CHP Medicare Summary of Benefits for Retiree Advantage

ARAG

ARAG Plan Summary
ARAG Rate Schedule

ARAG Legal Brochure
ARAG Plan Guide
ARAG Option 1 New Benefits-effective 1/1/2013

CNA

CNA Long Term Care Change/Term Form
CNA Insurance Detailed Plan Information
CNA Rate Schedule

Humana-CompBenefits

Humana CompBenefits Change Request Form
Humana CompBenefits Dental Claim Form
Humana CompBenefits Rate Schedule

MetLife

MetLife Beneficiary Designation Form
MetLife Change Request Form
MetLife Beneficiary Claim Form
MetLife Disclaimer Form
MetLife Rate Schedule 2012
MetLife Plan Booklet 2012
MetLife Your Benefit Plan
MetLife Will Preparation

Forms/Publications for Retirees

Name/Address Change Form
W4P Withholding for Pension or Annuity Form
Direct Deposit 175 Firefighter Form

Direct Deposit 185 Police Form
Direct Deposit 401(k) Form
Direct Deposit 457 RSVP Form
Direct Deposit DROP Form
Direct Deposit Pension Form
Additional Taxes on Qualified Plans (IRS Form 5329)
2013 Federal Income Tax Withholding (IRS Notice 1036)
Insurance Premiums for Retired Public Safety Officers
Non-taxable Pension Payment

Termination Distribution Forms (for Terminating/Retiring Employees only)

175 Firefigther Supplemental Share Termination Distribution Form
185 Police Supplemental Share Termination Distribution Form
401(k) MAP Termination Distribution Form
457 RSVP Termination Distribution Form
DROP Termination Distribution Form
Special Tax Notice regarding plan payments: 401(k) Map
Special Tax Notice regarding plan payments: 457 RSVP

Social Security Notice

Social Security Notice
Windfall Elimination Provision (Reduction of Social Security Benefit)
Government Pension Offset

Temporary Employees Information

Beneficiary Designation for Temporary Employee Form
Temporary Employees Information Sheet