Other Governmental Employment Service Credit Application

For GCERS' Members Purchasing Retirement Service Credit

GENESEE COUNTY EMPLOYEES RETIREMENT SYSTEM

1101 Beach Street - 3rd Floor

Flint, MI  48502

 810-257-2626                                                810-768-7097 (FAX)                                                800-949-2627

Section I:  Applicant Information (To be completed by the applicant and sent to the former employer's custodian of records)

 

Name:                                                               Birthdate:                               S.S. #

Mailing Address:                                                                                             Home Telephone:   

City, State and Zip:                                                                                         Work Telephone:

I authorize my employers to release all information requested in Sections II and III to the Genesee County Employees' Retirement System

 

    Member Signature:                                                                                                                           Date:  


Section II:  Employment Information (To be completed by the employer/custodian of records and sent to the Retirement System)

1. Name of Governmental Unit or Public School:

____________________________________________________

First day of employment :                                       ________________ 

Last day of employment :                                       ________________

2.  Compensation by calendar year (i.e., W-2 wages, January through December - attach an additional sheet if necessary

 

          ($              )

          ($              )

          ($              )

          ($              )

         ($              )

          ($              )

          ($              )

          ($              )

          ($              )

          ($              )

          ($              )

          ($              )

 

3.  Was this individual employed as a temporary, full-time, or part-time employee? (circle one)

 

4.  If temporary or part-time, please provide the hours worked per calendar year, or the hourly wage:

 

          (              )

          (              )

          (              )

          (              )

          (              )

          (              )

          (              )

          (              )

          (              )

          (              )

          (              )

          (              )

 

5.   Dates of any leaves of absence or breaks in service? _________________________________________

 

 

 

 

 

6.   Governmental Type:  City    Township      State        Village        County    Federal     Other

  (circle one)

 

 

 

 

 I certify that the information I have provided is true and complete to the best of my knowledge and in accordance with the law.

Governmental Official's Name:                                                       Title:

Signature:                                    Date:                                       Telephone:                                          

Section III:  Retirement Certification (To be completed by the retirement system's records custodian)

1.  Did the applicant participate in a retirement plan?                                                          Yes _______         No __________

2.  Was the plan a Defined Benefit Plan?                                                                            Yes _______        No __________

    If so:    Is the applicant currently eligible for a benefit?                                                 Yes _______        No __________

                   Is the applicant eligible for benefits in the future?                                             Yes ________      No __________

                    Was the applicant eligible in the past?                                                            Yes ________      No __________

     List all that apply (e.g. refunded, distributed, forfeited, on deposit, not vested)                   __________________________

3.  Was the plan a Defined Contribution Plan?                                                                    Yes ________       No _________

                    Were employer contributions made to the applicant's account?                       Yes _______        No _________

                    If YES, what is the status of those contributions? (e.g. refunded, distributed, forfeited,          __________________________

                    on deposit, not vested)

4.  If the applicant participated in a defined benefit and a defined contribution plan, was the plan converted from a defined benefit plan to a defined contribution plan?  Yes ________       No _____________

  I certify that the information I have provided is true and complete to the best of my knowledge and in accordance with the law            

Retirement System Official's Name:                                                                   Title:

Signature:                                            Date:                                                     Telephone: