Form Fb-0504-1100p Request For Userra Eligible Service
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1FB-0504-1100p
Division of Pensions and Benefits
Request For USERRA–Eligible Service
(USERRA = Uniformed Services Employment and Reemployment Rights Act of 1994.)
Check one:
Public Employees’ Retirement System
Police and Firemen’s Retirement System
Alternate Benefit Program
Teachers’ Pension and Annuity Fund
State Police Retirement System
Judicial Retirement System
Employee Section
Employee Name ___________________________________________________________________
Address _________________________________________________________________________
__________________________________________________________________________
Membership No. __________________________ Social Security No. ________________________
Date left public employment for uniformed service ________________________
Month
Day
Year
Name of former employer ____________________________________________________________
Dates of uniformed service from ____________________ to ____________________
(Attach supporting
documentation,
Month
Day
Year
Month
Day
Year
e.g. military orders)
___________________________________________
_________________________
Signature
Date
Employer Certification
Employer Name ___________________________________________________________________
Date of return to public employment _____________________
Month
Day
Year
Pensionable salary that employee would have earned during eligible period of military service
$____________. If not reasonably determinable, pensionable salary for the 10-month (ten month
employee) or 12-month (twelve month employee) period prior to departing for uniformed service
$____________. If employee was not employed by you prior to departing for uniformed service,
check here
and the Division will determine the correct salary to use.
STATEMENT: I certify that the employee shown above was eligible for pension benefits during the
dates of military service shown above under the provisions of the USERRA by returning to public
employment within the time period required by federal law. The pensionable salary to be used in
calculating back deductions is shown above.
___________________________________ _____________________________ _____________
Certifying Officer Name
Title
Date
For Division Use Only
Expiration Date ________________________________
Employee Contribution Rate ________________________________
Service Credited ____________
Months
Pay Periods
Salary Used ________________________________
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