APPLICATION TO PURCHASE MILITARY SERVICE CREDIT

I hereby make application for retirement credit for military service performed by me in accordance with MCLA 46.12 a(15) and the applicable provisions of the Genesee County Retirement Ordinance, Section 20b, and my union contract, if applicable.  A copy of my DD214 is attached.

Name (please print):

Social Security #:

Employee Department/Telephone # and Extension:

Employee Address:

Signature:  ____________________________________________

Date:  _________________________

THIS SECTION TO BE COMPLETED BY RETIREMENT OFFICE

Current Hourly Base Pay Rate	$
Current Hourly Longevity Rate	+
Current Hourly COLA Rate	+
Total Current Hourly Pay Rate Full-Time Annual Hours	$ x 2,080
Current Annualized Pay Contribution Rate	$ x .05
Annualized Contributions Amount of Military Service Credit	$ x
REQUIRED CONTRIBUTIONS	$