Retirement Program Election Form

Retirement Program Election Form
Employee Name:
Employee Date of Birth:
Retirement Plan Election: (choose either the Defined Benefit Plan or Defined Contribution Plan)
Check only one:
□
I elect the Defined Benefit Plan
State Employees’ Retirement System (SERS)
□
I elect the Defined Contribution Plan
Alternative Retirement Plan (ARP)
With your selection of the ARP plan, please indicate your choice of vendor, from any of the three current vendors
below. If applicable, allocate the percentage (must equal 100%) if more than one vendor is selected. Completion of an
enrollment application with your chosen vendor to allocate investments for your employee and employer contributions
will complete the process. Failure to complete an application will result in contributions invested in the default target
date retirement funds until you choose alternative investments. You may change your choice of ARP vendors up to two
times in a calendar year. Visit the vendor’s website for more information and to enroll online.
□ Fidelity
□ TIAA-CREF
□ VALIC
□
%
%
%
I elect the Defined Benefit Plan
Public School Employees’ Retirement System (PSERS)
If you are a current member of the Public School Employees’ Retirement System (PSERS), you may elect to
continue your enrollment with PSERS or elect SERS and opt for multiple service which combines service in both
SERS and PSERS to receive a single retirement benefit, or you may enroll in the ARP plan.
Certification:
I certify that I have received information regarding the retirement plans available to employees of Pennsylvania’s State
System of Higher Education. I understand that I have 30 days from the date of hire or eligibility to select a retirement
plan; otherwise, I will automatically be enrolled in the Defined Benefit Plan (SERS). Based upon the information
provided and with full knowledge of the options available to me, I hereby have made my choice of retirement plan. I
understand that this election is final and binding, and that I cannot change retirement plans after I have made my
choice.
___________________________________________
Signature
________________________
Date
Revised: 6/2015
I:\Human Resources\Personnel Services\BENEFITS\Sub Directories\Retirement\Retirement Program Election Forms\Retirement Program Election Form
2015.doc