RETIREMENT PLAN ELECTION FORM
ACADEMIC, ADMINISTRATIVE, and RESEARCH FACULTY
30 Day Election Period

Name:
Social Security #:

Date of Birth
Gender:
Daytime Phone:
Mailing Address:

PERA Retiree:  Yes  No

As a condition of employment, you must participate in either the Mines Defined Contribution Plan (MDCP) or in the Colorado Public
Employees Retirement Association Plan (PERA). To elect PERA as your retirement plan, you must be an active PERA member, an inactive
PERA member, or a PERA retiree with at least 12 months of PERA service credit. If you have worked at another Colorado Higher Education
Institution which offered an optional retirement plan and you made an irrevocable plan choice, that choice wil remain in effect at the School
of Mines. PERA retirees, however, may make a new plan selection upon rehire. Failure to return this form within 30 days of your date of
hire or eligibility will eliminate any option to select PERA (if eligible), and you wil be enrol ed in the MDCP.

RETIREMENT PLAN ELECTION
Mines Defined Contribution Plan (MDCP)
I elect to enrol in the MDCP. Go to www.valic.com and click on Enrol Now. Use the code 42465002

Elect the Disposition of your PERA Account
I do not have a PERA account or I am a PERA Retiree
I have a PERA account, and I elect the fol owing option:
 Terminate my PERA membership and authorize PERA to transfer al member contributions and interest
earned to the MDCP. By electing this option, I understand that I am waiving all future PERA benefits
associated with this account.
 Terminate future contributions to PERA but maintain my existing account with PERA. This option is available
only to individuals who have at least 12 months of PERA credited service. Member accounts with less than 12
months of PERA credited service wil automatically be transferred to the MDCP.

Public Employees’ Retirement Association (PERA)
I elect participation in PERA. I certify that have at least 12 months of PERA credited service credit as an active member,
an inactive member, or a retiree. I understand that PERA, not the School of Mines, determines my eligibility for PERA
membership. If PERA deems that I am not eligible, I wil be enrol ed in the MDCP.


I understand and acknowledge that:
 All of the information in this form is true and accurate
 My retirement plan election (MDCP or PERA) indicated above is irrevocable for the duration of this appointment at
the School of Mines, and unless I am a PERA retiree, wil apply to any future appointment at the School of Mines or at
any other Colorado Institution of Higher Education offering an Optional Retirement Plan.
 If my form is received after the payrol deadline (10th of the month), my deductions may be taken the fol owing month.
Please contact PERA Customer Service at 1-800-759-7372 with any PERA related eligibility or benefits questions.
Signature: Date:

PERA Verification  Yes  No per ___________ PERA Date: _______________ Eligibility Date: _________________