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Suite 350 Fairfax VA 22033 703-279-8200 TTY 711 1-800-333-1633 Fax 703-653-9543 www. fairfaxcounty. Form A00206/30/2017 Acknowledgement of Retiree Dental Insurance Termination Please check one box below Please terminate my retiree dental insurance coverage on last day covered. I intend to enroll as a dependent of a Fairfax County employee or as a re-employed annuitant. I understand that if I ever have a break in coverage I will never be able to re-enroll in retiree coverage in the future. I...
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01
Step 1: Obtain the acknowledgement of retiree form from your employer or retirement plan administrator.
02
Step 2: Read the instructions carefully to understand the requirements for filling out the form.
03
Step 3: Fill in your personal information, including your full name, address, contact details, and Social Security number.
04
Step 4: Provide information about your retirement plan, including the plan name, plan number, and date of retirement.
05
Step 5: Indicate whether you want to receive your retirement benefits in a lump sum or as periodic payments.
06
Step 6: Sign and date the form to acknowledge that the information provided is true and accurate.
07
Step 7: Submit the fully filled out acknowledgement of retiree form to your employer or retirement plan administrator.
08
Step 8: Keep a copy of the form for your records.

Who needs acknowledgement of retiree?

01
Employees who are retiring and receiving retirement benefits from their previous employer or retirement plan
02
Individuals who are eligible for a pension or other retirement benefits after a long career
03
Retirees who need to acknowledge their retirement and provide necessary information to their employer or retirement plan administrator
04
Anyone who is required to complete an acknowledgement of retiree form as part of the retirement process
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Acknowledgement of retiree is a form that confirms an individual's retirement status.
Retirees or individuals who have reached retirement age are required to file acknowledgement of retiree.
Acknowledgement of retiree can be filled out online or submitted through mail with the necessary information and signatures.
The purpose of acknowledgement of retiree is to confirm an individual's retirement status for administrative and financial purposes.
Information such as name, retirement date, retirement plan details, and signature must be reported on acknowledgement of retiree.
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