!HomeMailingAddress.PDF

Request for Retirement Initiation Packet {Includes Your Personal Retirement Proile) Submit this form 3-4 months before your retirement date to the Retirement Administration Service Center (RASC) via e-ax to: 1-800-792-5178 or via mail to: University of California - RASC, P.O. Box 24570, Oakland, CA 94623-1570. Your retirement packet will not be generated until you are within 90 days of your retirement date. • Name (Last, First, Middle Initial) : Campus Location : Birth Date • Daytime Phone I Home Phone I Retirement Date: I Separation Date I Email Address ! Home Mailing Address Do you anticipate any changes in your current appointment prior to retirement? D Yes D No If yes, please explain: ELIGIBLE SURVIVORS Do you have any eligible survivors? D Yes D No NOTE: A survivor may include spouse/domestic partner, dependent children (unmarried under the age of 18, or 22 if full-time student(s) or disabled), and/or dependent parents. If yes, please provide name(s), birth date(s), relationship(s) and ma iage/partnership date below: ! Name (Last, First, Middle Initial) • Birth Date • Relationship • Marriage/Partnership Date : Name (Last, First, Middle Initial) : Birth Date : Relationship • Name (Last, First, Middle Initial) : Birth Date • Relationship If you have a spouse/domestic partner, is he/she also a UC employee? D Yes D No If you have an eligible child, is he/she disabled? D Yes D No If yes, please provide the disability date: