Other Governmental Employment Service Credit
Application
For GCERS' Members Purchasing Retirement Service
Credit
GENESEE
810-257-2626
810-768-7097
(FAX)
800-949-2627
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Section
I: Applicant Information (To be completed by the applicant and sent to
the former employer's custodian of records) |
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Name:
Birthdate:
S.S. # |
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Mailing
Address:
Home Telephone: |
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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)
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1. Name of
Governmental Unit or Public School: ____________________________________________________ |
First day
of employment :
________________ Last day of employment :
________________ |
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2. Compensation by calendar
year (i.e., W-2 wages, January through December - attach an additional sheet
if necessary |
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($
) |
($
) |
($
) |
($
) |
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($
) |
($
) |
($
) |
($
) |
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($
) |
($
) |
($
) |
($
) |
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3. Was this individual employed as a temporary,
full-time, or part-time employee? (circle one) |
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4.
If temporary or part-time, please provide the hours worked per calendar year,
or the hourly wage: |
|
(
) |
(
) |
(
) |
(
) |
|
(
) |
(
) |
(
) |
(
) |
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(
) |
(
) |
(
) |
(
) |
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5.
Dates of any leaves of absence or breaks in service? _________________________________________ |
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6.
Governmental Type: City
Township
State
Village County
Federal Other |
(circle
one) |
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I certify that the information I have
provided is true and complete to the best of my knowledge and in accordance
with the law.
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Governmental
Official's
Name: Title: |
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Signature:
Date:
Telephone:
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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
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Retirement
System Official's
Name:
Title: |
|
Signature:
Date:
Telephone: |