(a) An employee of a covered employer who is receiving or is entitled to receive old-age insurance benefits under title two of the Social Security Act, may file with his employer and with the chairman a statement of facts supporting the employee's waiver of benefits and claimed exemption of the employee and employer from their obligations to pay contributions.

(b) If such statement, filed with the chairman, evidences the fact that like notice has been filed with the covered employer and the date of such filing, and execution of the statement has been duly acknowledged before a notary public, then on filing such statement with the chairman, the employee shall be exempt, effective at the beginning of the next payroll period following such filing, from liability to make contribution to the cost of benefits. The employer shall likewise be relieved of responsibility for providing thereafter for the payment of benefits to such employee, and the employee shall be deemed to have waived his rights to receive benefits.

(c) A like statement shall be filed with each new covered employer of such employee, and with the chairman.

(d) The chairman may, by rule, prescribe the form of statement.