APPLICATION FOR REFUND OF RETIREMENT CONTRIBUTIONS

APPLICATION FOR REFUND OF RETIREMENT CONTRIBUTIONS
GENESEE COUNTY EMPLOYEES' RETIREMENT SYSTEM
TO= : Retirement Commission			DA= TE: _______________________
Genesee County Employees' Retirement Sys= tem
I = hereby apply for a refund of all the accumulated employee contributions, with interest at the established rate, standing to the credit of:
Na= me _______________________________________________________________ Social Security # ________________________________________
Separated from employment with ______________________________________________________ effective _________________________________ = ; &n= bsp; = ; &n= bsp; = ; &n= bsp; (EMPLOYER) &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; (DATE)
due to _________________________________________________________________________= _____________________________________________ (REAS= ON FOR SEPARATION)=
I = fully understand the benefits of leaving my accumulated contributions on deposi= t in the Genesee County Employees' Retirement System (GCERS) and realize that = if I were not to withdraw this accumulation I may be eligible for a deferred retirement allowance upon written application to the Retirement Commissio= n.
I = also fully understand that the reciprocity provision of the GCERS that if I ha= ve at least two and one-half (2 1/2) years of credited service and leave my accumulated contributions on deposit in the GCERS and that should I be employed by another public employer whose retirement system is also a reciprocal retirement system, that I would be eligible for retirement benefits from the GCERS. I understand that should I withdraw my accumulated contributions from the G= CERS and later become employed with another public employer, I should immediat= ely obtain information concerning repayment of these refunded monies under reciproci= ty and any time limitations pursuant to the reciprocity provision.
I = also fully understand that if I am reemployed by an employer of the GCERS I ma= y be credited with the amount of membership service that I am forfeiting due to this withdrawal of retirement contributions, subject to the following conditions:
(1) Application is m= ade within twelve (12) months of reemployment.
(2) The membership s= ervice I was previously credited must have been service rendered for an employer participant of this = Retirement System.
(3) I deposit in the Genesee County Employees' Retirement System an amount equal to the aggreg= ate amount of contributions I made at the = time of the previous membership service plus interest compounded annually from the date of withdrawal of the accumulated contributions = to the date of deposit, at rates determined by= the Retirement Commission. If r= ecords are insufficient or unavailable to compute the exact = amount of required deposit, the Retirement Commission may estimate the amount.
(4) I deposit in the Genesee County Employees' Retirement System an amount equal to the the aggregate amount of contributions the = employer participant made at the time of the previous membership service = plus interest compounded annually from the date of = separation to the date of= deposit, at rates determined by the Retirement Commission.
Kn= owing these facts, I still hereby apply for all the accumulated contributions a= nd if applicable any interest to this member.
By= signing this application, I am authorizing the Retirement Office to contact the appropriate Personnel Department to confirm the last day of employment an= d to contact the appropriate Payroll Department to obtain current year to date contributions and that I am forfeiting my pension rights.
Wi= tness:		Ap= plicant:
_____________________________= ________________________ Signature	_____________________________= ________________________ Signature
_____________________________= ________________________ Name = Typed or Clearly Printed	_____________________________= ________________________ Name = Typed or Clearly Printed
_____________________________= ________________________ Addre= ss, Number & Street	_____________________________= ________________________ Addre= ss, Number & Street
_____________________________= ________________________ = ;City, State, & Zip Code	_____________________________= ________________________ City, State, & Zip Code
(_________)__________________= _________________________ Phone Number	(_________)__________________= _________________________ Phone Number
PLEASE ALLOW 6-8 WEEKS FOR REFUND DO NOT WRITE BELOW TH= IS LINE PLEASE ALLOW 6-8 WEEKS FOR REFUND
Last day of employment per Personnel Dept:_________________________________________ &nbs= p; Employer __________________________
Year-to-Date Contributions per Payroll Dept:__________= ______________________________
Total Accumulated Contributions: $____________________________________&nb= sp; Total Interest : $_______________________________________
Total Refund: $_______________________________________= ____ &nbs= p; &= nbsp; Date: ______________________________________________<= o:p>
Approved By:______________________________________________ Prepared By:_________________________________________________

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