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P.O. Box 942715 Sacramento, CA 94229-2715
888 CalPERS (or 888-225-7377) | Fax: (800) 959-6545
www.calpers.ca.gov
California Public Employees' Retirement System
Justification For Non Signature of Spouse or Registered Domestic Partner
Section 1
This form must be
completed if you have
a spouse or registered
domestic partner who
did not sign your
refund election
document
.
Requirement for Non Signature
Pursuant to Government Code section 21261, the member’s current spouse or registered
domestic partner must be made aware of the selection of benefits or change of beneficiary
made by a member. The spouse or registered domestic partner of a CalPERS member must
acknowledge the submission of a request for refund of contributions.
If a spouse or registered domestic partner’s signature does not appear on the above-named
document,the following information must be completed and submitted with the document.
Name (First Name, Middle Initial, Last Name) Social Security Number / CalPERS ID
My spouse or registered domestic partner did not sign the form because either:
I do not know and have taken all reasonable steps to determine the whereabouts
of my spouse or registered domestic partner; or,
My spouse or registered domestic partner has been advised of the application
and has refused to sign the written acknowledgement; or,
My spouse or registered domestic partner is incapable of executing the
acknowledgement because of an incapacitating mental or physical condition; or,
My spouse or registered domestic partner has no identifiable community property
interest in the benefit, or,
My spouse or registered domestic partner and I have executed a spousal or
or domestic partner settlement arrangement which makes the community property
law inapplicable. I certify under penalty of perjury that the foregoing information is
true and correct.
I certify under penalty of perjury that the foregoing information is true and correct.
Member Signature Date (mm/dd/yyy)
Collection and Access Information
Submission of the requested information is mandatory. The information is collected
pursuant to Government Code (sections 20000, et seq.) and will be used for
administration of the Boards’ duties under the Retirement Law, Social Security Act, and
the Public Employees’ Medical and Hospital Care Act, as the case may be. Portions of this
information may be transferred to another governmental agency (such as your employer)
but only in strict accordance with current statutes regarding confidentiality. Failure to
supply the information may result in the System being unable to perform its functions
regarding your status. You have the right to review your membership files maintained by
the System.
For answers to your questions concerning a refund of your contributions, please contact
the CalPERS Refunds Section, PO Box 942715, Sacramento, CA 94229-2715 or call toll-
free at 888 CalPERS (or 888-225-7377).
CalPERS Benefit Services Division • P.O. Box 942715, Sacramento, California 94229-2715
Mail to:
For questions
concerning your rights
under the Information
Practices Act of 1977,
please contact the
Information
Coordinator,
CalPERS, PO Box
942702, Sacramento,
CA
94229-2702.
