Certification Of Service And Final Salary - Retirement Form - Division Of Pensions And Benefits
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2RF-0239-0510
POLICE AND FIREMEN’S RETIREMENT SYSTEM
CERTIFICATION OF SERVICE AND FINAL SALARY — RETIREMENT
THIS FORM MUST BE COMPLETED BY EMPLOYING AGENCY — SEE INSTRUCTIONS ON REVERSE SIDE
1. NAME OF MEMBER _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
2. MEMBERSHIP NO. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
3.
SOCIAL SECURITY NO. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
4a. EMPLOYING AGENCY _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
4b. EMPLOYER LOCATION NO. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
5. DATE SERVICE TERMINATED ________/________/________ Applicant will not render any service to, or earn salary from this
agency after date service terminated. This date must be before the retirement date.
6. a) Is the member currently on suspension?
NO
YES If yes, give date of suspension _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Is suspension
Paid or
Unpaid
b)
Is the applicant facing or recently been considered for disciplinary action or indictment?
NO
YES If yes,
attach copies of the preliminary and final notices of disciplinary action or their equivalents or a copy of the indictment.
7. List unpaid leaves of one month (pay period for state locations) or more, without pay, within the last 12 working months.
REASON FOR ABSENCE
DATE OF ABSENCE (FROM - TO)
REASON FOR ABSENCE
DATES OF ABSENCE (FROM - TO)
TO
TO
TO
TO
8.
Base salary subject to pension fund contributions paid for the last full year of service ending on the date of termination (line 5
above). Please list number of months at the particular salary range, and show a total of 12 months for a 12-month employee or
10 months for a 10-month employee.
TOTAL
# ______________________ months @ $ ____________________ from __________________________ to __________________________ $ __________________________
# ______________________ months @ $ ____________________ from __________________________ to __________________________ $ __________________________
# ______________________ months @ $ ____________________ from __________________________ to __________________________ $ __________________________
# ______________________ months @ $ ____________________ from __________________________ to __________________________ $ __________________________
TOTAL BASE SALARY PAID FOR LAST YEAR OF SERVICE $ __________________________
9.
If the member received a significant annual salary increase in the last three years of employment, please attach a detailed
explanation along with supporting documentation such as salary guides, contracts, and ruling body minutes. If the explanation
or documentation is not attached, the processing of the member's retirement will be delayed until the Division receives it.
10.
Has there been any retroactive salary paid to the employee within the past three years? If so, please describe below:
AMOUNT OF
DATE OF
PENSION
NEW ANNUAL
PAYMENT
PAYMENT
COVERING THE DATES (FROM - TO)
DEDUCTION
BASE SALARY
$
TO
$
$
$
TO
$
$
$
TO
$
$
11.
The following deductions have been made or will be made from the member's base salary during the final two quarterly periods
including the quarter in which service terminated (see QUARTERLY REPORT OF CONTRIBUTIONS).
State biweekly reporting agencies should attach a screen print of TREADHOC biweekly certification with salaries projected until
termination date in lieu of Item 12.
BACK DEDUCTIONS
BASE SALARY
SUBJECT TO
ARREARS
TOTAL
QUARTER
CONTRIBUTIONS
PENSION
LOAN
NO.
AND/OR
PENSION
ENDING
THIS QUARTER
CONTRIBUTION
REPAYMENT
PAYMENTS
AMOUNT
PURCHASES
DEDUCTIONS
$
$
$
$
$
$
$
$
$
$
$
$
COMPLETED BY _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
PHONE NUMBER _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
E-MAIL ADDRESS _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
By signing this statement I am certifying, under penalty of perjury, to the truthfulness of the information contained herein.
SIGNATURE OF CERTIFYING OFFICER _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ DATE _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
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