Information Sheet

CONFIDENTIAL RETIREMENT SYSTEM INFORMATION SHEET

The information from this questionnaire will help us provide you with a computer projection showing what you could expect from the state retirement system pension and social security.

OPTION 1 OPTION 2 OPTION 3 OPTION 4 (CIRCLE ONE) DATE OF BIRTH: SPOUSE’S DATE OF BIRTH:

NUMBER OF PAY CHECKS PLEASE INDICATE THREE AGES YOU WOULD LIKE PER YEAR: TO SEE RETIREMENT FIGURES FOR: 1. 2. 3. TOTAL NUMBER OF YEARS WORKED IN NUMBER OF YEARS PRESENT ANNUAL SALARY PUBLIC EDUCATION IN MICHIGAN (As of 2/1/2013) WORKED IN CURRENT (INCLUDING SUBBING AND PURCHASED YEARS): SCHOOL DISTRICT: $ DO YOU PARTICIPATE IN A TAX SHELTERED ANNUITY (403B): YES NO AMOUNT PER PAY: $ I WOULD LIKE INFORMATION PENSION PLUS MIP BASIC YES ON BUYING YEARS OF SERVICE. (CIRCLE ONE) NAME: EMAIL:

ADDRESS:

CITY: STATE: ZIP:

HOME/CELL PHONE: SCHOOL:

SCHOOL DISTRICT: SCHOOL ROOM # BEST TIME TO REACH YOU: PREP PERIOD: TODAY’S DATE: