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Retiree Benefit Plan Enrollment

About this Form

Form number: 455-22

Audience:  MCPS Retirees

Last revised: October 2020

INSTRUCTIONS: All new retirees must make a selection in each category. 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 e-mail a PDF of the signed form to 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 e-mailed 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 Enrollment533 KEnglish

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