MmCalPERS

Section 1

» Plsaseprovtdeyour

name as it appears on

^ your Social Security card

Please display all dates m

this order monlh/day/yoar

Service Retirement Election Application888 CalPERS (or 888 225 7377) TTY (877) 249 7442

Please do not mail or deliver your application to CalPERS more than 90 days before your rehrement date

Information About You.

iTkowfts Pv m/ei-Name iFirsi ll.iina Midoie (ni(i»l LiMmme)

MOrers

CounliY

fjjliilala Oftnitleemf PhnndBirlli OatMRun/diY/Vfi liend^r iieinai' Pnan«

Section 2

Please enter the last day

you received compensabon

from CalPERS colored

employment

Please do not abbreviate

your employers name

orposihoP btle

The Temporary Annuity

benefit for which you are

eligible is based on your

CalPERS membership date

DonotfistSoaalSecunty

military or railroad

r^irement as aCaliforma

^Jwblic retiremei^system

u

I fcj,

-»

V —■> -1'I

zc.

OS

Information About Your Retirement

Please refer to Hie detailed instnicbcns in this publiCBtion

il'tUy 00 "Pw«U fmmliUmLaii tUy 00 PAyrotI rtnmMd/yyyyj

Emplenr

O3f2>l/zgt07Reli(«rn»nl Ctleclivt Ddie iranuddj|f<y)

Poviion Tltl4

Temporary Annuity If you select this benefit you must also fill out Section 3d Option 1 Balance ofCorlribuhons and/orTemporary Annuity Balance Beneficiary(iss)

To provide for an addibonal Temporary Annuity Allowance you elect to reduce your monthly allowancefor We ^0 DYesIf you first became a member on January 1 2002 or later you elect to receive Temporary Annuity untilage in the amount of ^

lOr to 701 Oollsis

The amount of your Temporary /Wnuity c^not exceed the estimated amount of your Social Secunty benefitat the age designated m this election

or

If you first became a member pnor to January 1 2002 you elect to receive Temporary Annuity until age

l.S9ii cc wBolc ag» 00 lo OSlin the amount of

Dol[v»per month

EfvteOther Calrfomia Public Retirement SystemsAre you a member of a California public retirement system other than CalPERS^ □ No SlYes provide

Mame of Sisiem

Are you currently working with the other system^ □ No SiVesI o^|^ll^o^^flslitemeni 03taV7iih Oihei Soiem imin:4a.7/>y]

STATE'Sexhibit /f ri,J

ij—-4 I'l

PERSBSD3nS(1/t&) Page I ol 8

Put your name and SocialSecurity number or CalPERS ID

at the top of every page

Select only one payment

opbon Option 1 Option 2

Option 2W Option 3

Opbon 3W the Unmodified

Allowance Opbon or one of

ttie Opbon 4 types

Itiese cpbons apply

to Opbon 4 Individual

Ijfebme Benefiaaiy only

Your Name

Select Your Retirement Payment Option and Beneficiary

By filling out this secbon you are electms your Rebrement Payment Opbon and designaUng your beneficiary

Your payment opbon elecbon and lifsbme beneficiaiy(^) designabon is irrevocable unless you request a changewrthm 30 days of the issuance of your brst banefrt check ̂ you have a future qualifying event Along with your opbonselecbon you must complete at least one of the tienebcia/y designabons in Sections 3a-3d Please refer to the detailed

mstrucbons in this publicafaon for more information

^Q'^ption 1 To complete this option you must also fffl out Section 3d Balance of Contnbutions Benericary

^^0^QTr2''-To complete this option you must also fill out Section 3a Indtvidual Lifetime Beneficiary□ Option 2W - To complete (his option you must also fill out Secbon 3a Indivtdu^ Lifetime Benefiaaiy

□ Option 3 To complete this option you must also fiO out Sadion 3a fod/wdus/ UfeJima Bmeficary

□ Option 3W To complete this option you must also hll out Secbon 3a Indmduaf Lifstimg Benefxary

□ Unmodified iUlowanco Option if you select this (qibon there is no return of your memtter conbibutions andno monttdybMefrtspayableupon your death—excepttheSurvivorConbnuanceBonelit ilappbcable Ttiereisftobeneficiary destgn^on for this opbon

□ Option 4, Individual Lifetime Beneficiary i( you select this i^ition you must also select one of the followingIndividual Ufetlme Benehciay opbcns below

□ Option 2W & Option 1 Combined To complete this option you must also fdl out Secbon 3a fmfmduafUfetime BenefxtaiyanA Secbon 3d fia/ance of Coiitnbutms Benafiaary

□ Option 3W&Opbon 1 Combined TocompietsthisiHition you must also fdl out Secbon 3a individualU/etime Banefiaaryani Secbon 3d Balance ofContnbulions Benehaary

D Specific Dollar Amount to Beneficiary 5Secbon 3a indmdmlLifelim Beneficiary

To complete this opbon you must also hll out

□ Specific Percentage to Beneficiary % To ccmpieie this cpoon you must also (iH outSectonSa Indiv/duaf Lifetime Beneticiaqf

□ Reduced Allowance for Fixed Penod of Time

Reduce my Ailowance by! or % through the end ofOonitn PMcni D3ia inmiiriinr)

To coms^le this opbon you must also (ill out Secbon 3a ItutiMu^U^fme^neAaa/y

□ Reduced Allowance upon death of retiree or beneficiary *. reduction amountOoOiHS

10 complete ths opbon you must also fill cut Secbon 3a Individual UtBtaneBen^oaiy

This opbon applies toOption 4 MuttmtB Lifetfine

Beneflaanes only

These opbons apply toOpbon 4 Court Ordered

Community Property only

□ Option 4, Multiple Lifetime Beneficiaries To complete this opbon you must also fill out Section 3bl^ultiple uptime Beneflciams

D Option 4, Court Ordered Community Property it you select this opbon you must also complete Secbon 3cCourt Ordered CP Benefiaaiy and select one of the following Court Ordered Community Property options

O Option 4/Unmodifl8d There is no addibonal beneficiary designation for this option

□ Option 4/1 To complete this opbon you must also (iO out Secbon 3d Balance of Cordnbubons Benebaary

□ Option 4/2W To complete this opbon you must also (ill out Secbon 3a Individual Liletime BenefKaiy

□ Option 4/3W To complele this option you must also hH out Secbon 3a Indmdual Ufotme Benebaary

PEflSBSO SeSSfWlS)

Pid your name and Social

Secunty ndmbsr or CalPERS IDat the top of every page

Section 3a

Designate one tieneficiary

and provide all of that

person $ information

including fuP name

Social Seearily Number or CalPEflS 10

Option 2,2W, 3,3W, or 4 fndiuiduai Lifettme Beneficiary

Complete this section only if you chose either Opbcn 2 2W 3 3W or Option 4 Individual Lifetime Benefictaiy or

Opl«n 4y2W or 4/3W Court Ordered Community Property ^

lUiMOflr SHamaffinitlamt MuMlelnituI LaU ilaov| Social Secunty Nanbar uf CalPBtS 10

I □ Man'O FemaleB'lUi Uaitt immi'i]

I 6-1^6 L3:>'SR<tiiionsa>9 to Yes

Option 4 MuUiple Lifetime BeneficianesIf you wont Complete this secbon only if you selected Opbcn 4 Midtiple Ufeiuno Beneficianes

your beneficianes toreceive an equal share

of your benefits donot specify a dollar orperceniage of benefil

UtnisrFvUNurc Uiddielmtul Uniiaraei

e«ih Pats poia/Mrnrrl[□Male OF^Getuer

Saoii Sea iiv Nambet o' Caffeas 10

BeiitMunv to You OdAnnvrcmi tf B»oera

Sitta ziy

Name iFosi NaiM MicMia imiiai laai Heme)

I iDuais QPwabe4lliDiie(nm;eo.-]fjry?i GeuOei

Sccial SecuKlf Number ot CaiPERS ID

Rciaiionsixa tc vvu Dc'U/rPersanl ol BsfiHit

Suit TIP

riJBir ifoel Name UidOli iniiial Last Memcl

I lOLble □fMBieeino Date laiVMr/irnt GuuMf

S403I Secttfily Number or CatPSKS iD

RrtabMtsitip lo Vm OoP«>T0cefll qI SsaeM

Suit TV

PERS8S)3eeS{l/1Sl PaqoSoie

Put your name amfScctalSecurity number or CalPEAS ID I

atUifltopofevfiiypafle ^o'Narae Social Security Kombsr et CatPSRS ID

Section 3c Court Ordered Option 4 Community Property Beneficiary

List only the Dimplele Ihis section only rf you selected Option 4 Court Ordered Community Property

Option 4 benefiDary

WB.e,u.r«Ilv)roLr >..idr. in,.uiiSoOii StfWilr

court order HBiaorr or CalPERS ID

Bir h Doio {nmlCd/rvTri

iDuiIb QFrrnaleCewier neuiiMQtup to Ymi

Section 3d

O^ignate up to three

lieneftcianes here it you

want to designate more

than Uiree benelicianes

you win need to complete

ttie Post Retwment

Lump Sum Beas/tttsry

Designation torni and

loltow the instructnns

on the form

Optioni Balance of Contnbutions and/or Temporary Annuity Balance Beneficiary(ies)

Contplete this section only il you selected Option 1 Option 4 ZW/1 or 3W/1 combined or the Temporary Annuity

allowance You may change this beneliaaiY(ies) at any lime This designalran automatically revokes when there is a

change in your mantat status domeshc partnership status or when there is a tnrlh or adoption ot a child Please refer

lo the detailed instructions in this publication for more infcrmation

tUoi» iFusi liani Udale mnai Lcu Namn

! iPMjie Dtewlr IBulP Ocio tmiR»U>)3rrr) Cqiwn R«l3bw>iiip ic vou

Sooai Scuiiir Hbibki m C&U%RS lO

iOhwiv PSHamfi IPneiitr PeKem ft BtACfn

if you want your

benehcianes lo receive

an equal share of your

benefits do not speafy a

percentage ot benefit

N-uw iFitt Uam UkMK ln>ti;il Last U»«H

1 iPMria Ofwio IB(RP Dale imn/dutn/i fendei (KbboMhiot&tbu

ilPCodi Cnairjr

SecJii S«nmr NumMr« CeiPERS 10

I Dftgnuy^lonly PeKtaiMBenefii

ZiPCode CeuBtir

funeiFuniUiM u^meiaitai Ustiiamn

1 iQuiie DPhmm 18nlB OsK Inn/dUnnrTT) Ctetftr Reillionsbplenni

SMnl Swuiitr Htmbei 01 CalPERS lO

I DPiiamv □{PflMAy Pffrent ot Benetit

7IP co4« OounUT

renSBSO 3i$9S(Ul5)

Put your name and SocialSecurity number or CalPCRS ID

at the bp of every page

Section 4

If you were last employed

with andUter California

^ public retirement system

S this benefit is not payable

tn

» If you want your

^ beneficianes b receiven

;; an equal share of your

H benafib do not specify a

percentage of benefit

Your Name Soda, .iurlty Number or CalPERS 10

Retired Death Benefit ^ ̂ QQThis section designates the person who will receive your Lump Sum Retired Death Benefit You may change this

beneficiaiyties) at any bme This desi^ation automabcaUy revokes when there is achanqe in ycur cnantal status

domestic partnership stabs or when there is a buth or adoption of a child Please refer to the debiled instnictionsm this publicataon for more information

Lwa- s Vfruog-ziltai LaMllomri

iDlilale IBini> OaK- {mm.'tfd.'yyyi'l CtnOfi Iteiaiiofaiua lo'rtrij

Silt Ul SciuMl/ llumOtf Of CjIPERS 10

I PPniTonf Gfoifno'itr PcitsniolS^nftlit

lUm*- [Pitsl N^nvf MiOOl' initial Usi Hanoi

I iPMata pFKnttc I

eirili Oale |inai.'dd'ynni GonOot ReiMiODidplo You

S>]cial Sartnily liombfrr or CalPEflS 10

I □PiinaiY □SeconflPf IPfi<iiir7 htfcrn el SEneiit

2lP CuOt Comtrr

Name ihrsi Nqme MiCdie (miul Lad Name)

\ iQwiafe GriimMfr IOinri Oatf imnvdd.'vnfyi Gendn ncUtumNiio lo ym

Social Secufiiy Nuiriber or CoiFtRS 10

iDPnttniy DSoiyifPrioritr ^icefll Oi Beaabt

ZlPCoOo Couolir

Section 5 Survivor Continuance

Please refer to the detailed instructions rn this publication tor more informabon1 Vlil! you be manned on your rebremsnt date'' QNo^P Yes provide

|i V.\NlOA S VlArL^€'^ I BUmWIName oi SoouM 'Pusl Niinir Miooie Iniltal loii Mamr] Socul Svcuniy lluaitiF-r ot CalPERS 10

Bulo D-ila |(am/(m<vv«IDMiIo ^whIoClflSW Dale at M<irnsge

Section S continues on page 6

PER3BS0 369SlinSi

Put Jfour name and Social 0 Ml^tSecuntynumbBrorCalPERS ID I » ^ I*" ^ rrwc ̂

at the top of every page ''®""

Section 5, continued Survivor Continuance, continued

2 Will ycu be registered witit the California Secretary of Slate as being m a domestic partnership on

your retirement date^ ^No DYes provide

fUois ol Domnuc Poclner tFost Uine Mififiie lailiai Uit IJdtne)

) iPHiiB DfaniieBirta Oat« I'nn/dd/yyyy) Gttidtr

Social Secutllf Kumtid oi CalPERS 10

Oaifl ol RiBKieied Pattnetobip

Staif ZIP

3 Do you have any natural or adopted unmamed children under age 18? □ No ^lYes provide

I JcMWTUiys/ -SN Same el CMS <Risi Nirap Uiooleiaiutl last Mane) ociil Seruiitv NukM' « CalPERS 10

B<nn Dais imm-Wmr) Ctnder

liane o> CaUd iFtrn Mama Midflla Intiiai Laol Njiroi

Birtn Dale iinn-'dt^'vnry)inMMa □fetBaieCdoder

Soaal Secuiitf Numt>et or CalTERS lO

&»t« ZIP

4 Do you have^pny unn^ed ctuldren v»ho were disabled prior to their 18lh birttiday and who are stilldisabled?^No^Yes provideI ̂ N/YVCQtg^ IN Social Soconly Nuffl&ef oi CalPBlS K)ftme ol Ctidd (PiiM Name Mtddle iniiial Last Nano

□FomoteBirtii Pate »mpf(

Slate VP

Name «il Child iFtiU Nome idioditimui UsOiame)

I jpfajM □FfCrUleBmh file (iran/dd/mil Geodai

50(131 sceurilf Nunhei v CtdPCRS lO

Sttte D?

Section S conttnufls cn page 7

PERSBSO zesSU'lS)

Put your name and SocialSecurity number or CalPERS ID

at the top of every page Tour Name Social .utity Number or CalFERS ID

Survivor Continuance, continued yj5 Are your parents dependent upon you for one halt of their support?^^ No □ Yes provide

Name ot farenl (Fiisl Niimr MlCdls InitiAl Lai! Namo)

Birlh Dale (mflVM/imfyitPrw DhiniieGender

Social Seconiy Nurabtr or O-urfRSlO

Tax Withholding ElectionPlease choose one only Federal Income Tax mtonnation Please reler to the detailed instructions m this publication lor more information

C^p'oot withtiotd federal income taxff^Withhold federal income tax based on the tax tables for

□ i^amed individual with tax withholding allowancesjy HymberA single individual with_0_tax withholding allowances

Number ^In addition to the amount withheld based on the tax tables withhold ̂ per month

Dollars

□ A mamed individual but withhold at the higher single rate with .tax withholding allowancesNumber

Please choose cr« only State (ncome Tax mformatian Please refer to the detailed instructions in this publication for more mfomiation

State withholdingIS optional for

out of state residents

□ Do not Withhold State of California income tax

□ Withhold State of Cairforma income tax in the amount of . per month

/P^Withhold State of California income tax based on ttte tax tables for□ A mamed individual with tax withholding allowances

yff Number/JS A single mdmdual with tax withholdmg allowances

Number

□ A head of household individual with tax withholdmg allowancesNumber .

In addition to the amount withheld based on the tax tables withhold s Iffo per month

□ Withhold State of California income tax m the amount of 10 percent of the federal income taxwithholding amount

CalPERS Health Coverage "it you are currently enrolled in your own nghl tor CalPERS healfh benefits you can continue your heatUienrollment into retirement with no break in coverage

If you do not want health coverage you must cancel retiree health coverage by declining coverage belowVbu may be eligible to enroll in health coverage dunng the next Open Enrollment period

□ i decline conbnuation of my CalPERS health coverage rnto rebrement

PERS Bsoicesinre}

Put your namo and Social

^unty number or CalPEfiS IDat the lop o( every page

Section's

This section must

be completed or

your appticalion will

be returned

Your signature and your

spouses or domestic

partner s signature must

bo noianzed by a notary

public or yjiinessed by a

CalPERS representative

If your spouse s or domestic

partners signature is

not available see

instructions in this

publication (or completing

the JustjfJeabon for

Absence of Spouse s or

Registered Domestic

Partners Signature form

YourHami Social Security Number or CalPERS 10

Member Signature and Notary

1 certity under the penalty of perjury that the inlormation submitted hereon is true and correct to the best of

my knowledge I understand that to cancel this application or to change the elected payment option or lifebme

beneficiaryOes) I must notify CaiPEBS withm 30 days of the issuance of my first retirement benefit check

1 understand that tl I am mamed or in a registered domesbc partnership t}ut do not name my spouse or partner

as beneficiary they may still be entitled to a community property share of the Option 1 lump sum return ol

contributions benefil or a share of the monthly option death benefit allowance Their community property

interest is 50% of the benefit based on the contributions or service credit earned for the period of CalPERS

service during which we were marned or in a registered partnership My non spouse or non partner designated

beneficiary will receive the portion of the lump sum Option I benefit or monthly option allowance that is not

payable to my spouse or domestic partner I understand that my spouse or domestic partner will have the right

to disclaim entitlement to their community property interest m the death benelit at the time the benefit becomes

payable if they so desire

More detailed informabon on this section is available in this publication

Are you legally marned or do you have a legal domestic partner'^ ^Yes QNoIt yes your spouse or domesbc partner must sign this election

If no please indicate □ Never Mamed/orm Partnership □Divorced/Annulled□ Wido^d oj^erminabon ol Oomestrc Partnership

YouiS^aiuie t ^ Oala traia-dd-VyvTl

icallo,Lacy_ULvnur S^ie s or Ooiocr.l>c Partner $ Signature Ualt- {mm-'>ld.'>Y¥i'l

YourS^aiuie tv / v Dale traia-diJ'VyvTl

icQ/.ioLac:a-ij-vnur S^ie s or Oomcr.l>c Partner $ Siqnaiure Uatt- {min-'>ld.'>YYYl

Slate Of California County of

On before meOat« NameQlNaiary/'WilnefS

personally appeared who proved to me on the basis of satisfactory evidenceto be the personfs) wiicse name(s) is/are subscnbed to the within instrument and acknowledged to me thathe/sherthey executed the same m his/her/lheir aulhonzed capacily(ies) and that by his/her/their signaturefs)on the instrument the personis) or the enbty upon behalf of which (he personfs) acted executed the instrumentt certify under Penalty of Pei]ury under the laws of the Slate of California that the toregcir^ paragraph ts trueand correct

Notary Seal

Witness my hand and offi^ seal or authorized CalPERS representative signature

Signature ul Kc-tniy or CulPERS H' prKtntai^

I ̂ Lg. ^hmiNamt

. OakimiTu'daifml '

CalPcFlS Ctil'cg i.ii dppl<U9ie)

Mail to: CalPERS Benefit Services DivisioniPO:Box9427irSacfamento"CaIifomia 94220711'