1. MEMBER INFORMATION FORM
      1. Return completed form to your employer.
      2. For plan, contribution rate and investment program selection
      3. New members*
      4. Members transferring from Plan 2 to Plan 3
      5. Returning Plan 3 members
      6. Check One:
      7. SECTION 1: Personal Data – To Be Completed by All Members
      8. SECTION 2: Retirement Plan Selection
    1. Complete either A or B below.
      1. A) To be completed by new members.*
      2. B) To be completed by any Plan 2 member eligible to
      3. transfer to Plan 3.
      4. Total Member
      5. Contribution Rate
      6. RETURN COMPLETED FORM TO YOUR EMPLOYER.
      7. SECTION 5: To Be Completed by Employer
      8. Employers:
    DRS MS 133 (R 10/08)
    Page 1 of 2
    MEMBER INFORMATION FORM
    Return completed form to your employer.
    For plan, contribution rate and investment program selection
    New members*
    Choosing Plan 2 - Complete Sections 1 and 2A
    Choosing Plan 3 - Complete Sections 1, 2A, 3 and 4 and
    submit to your employer within 90 days of your date of hire
    Members transferring from Plan 2 to Plan 3
    Complete Sections 1, 2B, 3 and 4
    Returning Plan 3 members
    Complete Sections 1, 3 and 4 and submit to your employer
    within 90 calendar days of your date of hire
    Check One:
    F
    TRS = Teachers’ Retirement System
    F
    SERS = School Employees’ Retirement System
    F
    PERS = Public Employees’ Retirement System
    SECTION 1: Personal Data – To Be Completed by All Members
    Name (Last, First, Middle)
    Social Security Number
    Maiden Name
    SECTION 2: Retirement Plan Selection
    Complete either A or B below.
    A) To be completed by new members.*
    Choose One:
    F
    Plan 2
    F
    Plan 3 (requires completing sections 3 and 4 on back)
    I certify that I have chosen the retirement plan marked above.
    I understand that my retirement plan selection is
    irrevocable
    .
    Member Signature (required)
    Date
    Please sign and date this form on the day that you
    submit it
    to your employer
    . Note: You will be assigned to Plan 3 if your
    employer has not received your plan selection within 90 calendar
    days from your date of hire.
    *New member
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    DWDKLJKHUHGXFDWLRQRUVWDWHDJHQF\HPSOR\HURUZKR¿UVW
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    B) To be completed by any Plan 2 member eligible to
    transfer to Plan 3.
    I certify that I have chosen to transfer from Plan 2 to
    Plan 3. I understand that my selection of Plan 3 is
    irrevocable
    . I have provided the information requested in
    Sections 3 and 4 on the back of this form.
    Member Signature (required)
    Date
    Please sign and date this form on the day that you
    submit it to
    your employer
    .
    DRS MS 133 (R 10/08)
    Page 2 of 2
    SECTION 3: Selection of Contribution Rate – To Be Completed by All Plan 3 Members
    Place a check mark in the box next to the contribution rate option you choose.
    If you do not select an option within
    90 days, your default will be Option A. Once established by selection or default, you may only change your contribution
    rate option when you change employers. The only exception is that the IRS currently allows TRS Plan 3 members to
    change their rate option each January. The IRS could end rate change options at any time.
    Base Rate
    Additional Rate
    Total Member
    Contribution Rate
    F
    Option A
    All ages
    5.0%
    0.0%
    5.0%
    F
    Option B
    Up to Age 35
    Age 35 to 44
    Age 45 and above
    5.0%
    5.0%
    5.0%
    0.0%
    1.0%
    2.5%
    5.0%
    6.0%
    7.5%
    F
    Option C
    Up to age 35
    Age 35 to 44
    Age 45 and above
    5.0%
    5.0%
    5.0%
    1.0%
    2.5%
    3.5%
    6.0%
    7.5%
    8.5%
    F
    Option D
    All ages
    5.0%
    2.0%
    7.0%
    F
    Option E
    All ages
    5.0%
    5.0%
    10.0%
    F
    Option F
    All ages
    5.0%
    10.0%
    15.0%
    Member Signature (required)
    Date
    SECTION 4: Selection of Investment Program – To Be Completed by All Plan 3 Members
    Place a check mark in the box next to the investment program you choose. If you do not choose an investment program,
    your contributions will be reported into the Washington State Investment Board (WSIB) Investment Program:
    F
    Washington State Investment Board (WSIB) Investment Program.
    F
    Self-Directed Investment Program.
    You must choose how your contributions will be invested. You may do so
    online at http://www.icmarc.org/plan3, by phone at 1-888-711-8773 or with a Plan 3 Self-Directed Investment
    Allocation form.
    As of October 6, 2008, if you do not make a choice your contributions will be invested in the 2010 Retirement
    Strategy Fund.
    You can obtain information about both investment programs by contacting ICMA-RC toll-free at 1-888-711-8773.
    Member Signature (required)
    Date
    RETURN COMPLETED FORM TO YOUR EMPLOYER.
    SECTION 5: To Be Completed by Employer
    Print or type employer name and mailing address below:
    Reporting Group
    Employers:
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    Department of Retirement Systems
    PO Box 48380
    Olympia WA 98504-8380
    Toll Free: 1-800-547-6657
    Local: 360-664-7000
    Department of Retirement Systems (DRS) requires that you provide your Social Security number for this form.
    ‡
    DRS will use your Social Security number as a reference number and to ensure that any funds disbursed under
    your account are correctly reported to the IRS.
    ‡
    DRS will not disclose your Social Security number unless required by law.
    ‡
    Internal Revenue Code Sections 6041(a) and 6109 allow DRS to request your Social Security number.

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