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Retiree Benefit Plan Enrollment - FOR NEW RETIREES ONLY

Employee and Retiree Service Center (ERSC)

About this Form

Form number: 455-22R

Audience:  MCPS Retirees

Last revised: March 2022

All new retirees must make a selection in each category of MCPS Form 455-22R. If you are a retiree making changes during Open Enrollment or after experiencing a qualifying life event, or you wish to update your beneficiaries, you must use MCPS Form 455-22.

Complete, sign electronically or manually on both sides of this form, and return to the Employee and Retiree Service Center (ERSC). You may fax the signed form to 301-279-3651 or 301-279-3642, or email a PDF of the signed form to ERSC@mcpsmd.org. This form must be signed at the bottom of pages 1 and 2. Please do not mail copies to ERSC once you have faxed or emailed the enrollment form. A confirmation of your requested change(s) will be sent to you. Unsigned forms will be returned to you and become your responsibility to resubmit to ERSC by the appropriate deadline.

Adobe PDF Retiree Benefit Plan Enrollment - FOR NEW RETIREES ONLY
Employee and Retiree Service Center (ERSC)
182 KEnglish

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