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Retiree Benefit Plan Enrollment

About this Form

Form number: 455-22

Audience:  MCPS Retirees

Last revised: March 2022

INSTRUCTIONS:  Retirees making changes to their benefits during Open Enrollment or due to a qualifying life event, or those 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.

Make a selection in each category of the correct form as explained above. Sign the form electronically or manually on both sides, and submit it 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 The 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 Enrollment137 KEnglish

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