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Retiree Benefit Plan Enrollment (2023)

About this Form

Form number: 455-22

Audience:  MCPS Retirees

Last revised: September 2022

Retirees making changes to their benefits during Open Enrollment or due to a qualifying life event, or who wish to update their beneficiaries must use MCPS Form 455-22. New retirees initially enrolling in retiree benefits must use MCPS Form 455-22R.

 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 email 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 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 (2023)145 KEnglish

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