APPLICATION TO PURCHASE PRIOR COUNTY REFUNDED TIME

Retirement Ordinance: Section 17

Except as otherwise provided in this ordinance, should any member leave the employ of an employer, for any reason except his retirement or death, he shall thereupon cease to be a member and his credited service at that time shall be forfeited by him.

In the event he is reemployed by an employer, he shall again become a member of the retirement system.  Upon reemployment his credited service last forfeited by him shall be restored to his credit upon his repayment of monies as specified in Section 21 of this ordinance.  Application by the employee for restoration of such credited service last forfeited shall be made within the period of twelve months commencing on the date of rehire.  Upon retirement or death of a member, he shall thereupon cease to be a member.

I am requesting to repay the previous refund of my retirement contributions, plus interest, and employer contributions if required, in order to credit my prior county time refunded to my current service date for retirement.

 

Name (please print):

 

Social Security #:

Employee Department/Telephone # and Extension:

 

Employee Address:

 

 

Signature:  _________________________________

Date:  ___________________