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Directory Results for Augusta, ME 04332-0349 Telephone: (207) 512-3100 Toll-free: 1-800-451-9800 Fax: (207) 512-3101 TTY: (207) 512-3102 CERTIFICATION OF SPOUSAL NOTIFICATION Retiree s Printed/Typed Name Social Security Number Retiree s Spouse s Printed/Typed to Augusta, ME 04332-0349 Telephone: (207) 512-3100 Toll-free: 1-800-451-9800 TTY: (207) 512-3102 Fax: (207) 512-3101 SURVIVOR BENEFITS Recipient 's CERTIFICATION Name of Deceased Member: SSN: Name of Student: SSN: Name of School: School

Augusta, ME 04332-0349 Telephone: (207) 512-3100 Toll-free: 1-800-451-9800 Fax: (207) 512-3101 TTY: (207) 512-3102 CERTIFICATION OF SPOUSAL NOTIFICATION Retiree s Printed/Typed Name Social Security Number Retiree s Spouse s Printed/Typed
Augusta, ME 04332-0349 Telephone: (207) 512-3100 Toll-free: 1-800-451-9800 Fax: (207) 512-3101 TTY: (207) 512-3102 Employee Name: First Prefix consent designating authorized representatives MI Last Suffix Social Security Number: I
Augusta, ME 04332-0349 Telephone: (207) 512-3100 Toll-free: 1-800-451-9800 Fax: (207) 512-3285 TTY: (207) 512-3102 MAINE PUBLIC EMPLOYEES RETIREMENT SYSTEM EMPLOYMENT CONTACT FOR THE MONTH OF: Recipient Name: Social Security #: (Please
Augusta, ME 04332-0349 Telephone: (207) 512-3100 Toll-free: 1-800-451-9800 TTY: (207) 512-3102 Fax: (207) 512-3101 SURVIVOR BENEFITS Recipient 's CERTIFICATION Name of Deceased Member: SSN: Name of Student: SSN: Name of School: School