Form R0890d - Retirement Application For Spousal Benefits
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1
2Department of Technology, Management & Budget
Office of Retirement Services
(800) 381-5111
P.O. Box 30171
Lansing MI 48909-7671
Retirement Application for Spousal Benefits
For Michigan National Guard State Military Retirement
YOUR NAME (LAST, FIRST, M.I.)
YOUR SOCIAL SECURITY NUMBER
YOUR BIRTH DATE (MM/DD/YYYY)
MAILING ADDRESS
DAYTIME TELEPHONE
SEX
(
)
MALE
FEMALE
CITY, STATE, ZIP CODE
EMAIL ADDRESS
As the surviving spouse of a former member of the Michigan National Guard, you may be entitled to military survivor
retirement benefits from the state of Michigan. Survivor benefits of $500 per year may be payable under the following
statutory authority: Sec. 411(3), Public Act 150 of 1967, as amended. To apply for these benefits, authorize your tax
withholding, and set up direct deposit for your pension, complete this application and send it with all required proofs to
the Office of Retirement Services (ORS).
Section I – Retirement Eligibility
Your spouse must have met the following eligibility criteria for you to qualify for a survivor’s retirement benefit.
•
Served a minimum of 19 years, 6 months, and 1 day in the Michigan National Guard (Army or Air or both).
•
Separated from the Michigan National Guard.
•
Was at least 55 years old at the time of death.
Section II – Retirement Application
Complete the following information regarding your spouse.
SPOUSE’S NAME (LAST, FIRST, M.I.)
SPOUSE’S SSN OR MEMBER ID
SPOUSE’S BIRTH DATE (MM/DD/YYYY)
SERVICE CATEGORY
RANK
DISCHARGE DATE
Air National Guard
Army National Guard
BOTH
Spouse received an HONORABLE DISCHARGE or separation
Note: If other than an honorable discharge or separation, provide a full explanation of the circumstances with this application.
Additional Documentation Required. You must include all of the following documents with your application:
•
Copy of your spouse’s death certificate
•
Proof of your birth (photocopy of birth certificate, baptismal certificate, or passport)
•
Photocopy of your marriage certificate
Section III – Income Tax Withholding Authorization
This authorization is effective with your first pension payment and continues until you change your withholding online
through miAccount or file a new form. If you leave the Federal section blank, ORS must withhold taxes as if you are married
claiming three allowances.
Federal Tax Withholding – Your Michigan military pension is subject to federal income tax.
1. Check here if you don’t want any federal income tax withheld from your pension. If you check this box don’t complete lines 2, 3 or 4.
2. Total number of allowances you are claiming for federal withholding from each pension payment.……………………………………...
(allowances)
3. What is your federal withholding status? (Required)
Single
Married
Married but withhold at higher “Single” rate
4. Dollar amount, if any, you want withheld from each pension payment in addition to your standard federal withholding
amount. You must enter a number on line 2 (including 0) BEFORE you fill out line 4.
$ _________
Continued on page 2
R0890D (Rev. 4/2014)
*000585000000000I*
Authority: 1967 P.A. 150, as amended
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