Form Orp-Refund-1 - Application For Refund Of Voluntary Employee Contributions Only - State University System Optional Retirement Program (Susorp) Page 2

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*FF*
ORP – REFUND–1
State University System Optional Retirement Program (SUSORP)
Effective 11/15
Application for Refund of Voluntary Employee Contributions Only
Division of Retirement – OAP/ORP Section
PO Box 9000
Tallahassee, Florida 32315-9000
Phone: 850-778-4696 Toll-free: 877-378-7677 FAX: 850-410-2030
Email:
I.
Contact Information:
Member Name: _____________________________________________ Member SSN:_____
Home Mailing Address:
__________________________________________________ __
Email:_______________________________________________________________ __
Home Phone: ________________________ Work Phone: ______________________
II. Member Certification: (sign in the presence of a Notary):
I am requesting a refund of only my voluntary employee contributions in full or partial from my SUSORP account. I
understand that I cannot receive a refund from my SUSORP account while I am employed in any capacity with any
employer participating in the Florida Retirement System (FRS). I have terminated or will terminate all employment with all
FRS employers on (date) ________________.
I understand that I am not eligible to receive a refund of my voluntary employee contributions from my SUSORP account
until I am terminated from all employment relationships with all FRS employers for three full calendar months in
accordance with Paragraph 121.035(5)(g), Florida Statutes. For example, if I terminate employment on June 6, the
earliest that I am able to receive a refund of my voluntary employee contributions from my SUSORP account is October 1.
I further understand that in requesting a refund of my voluntary employee contributions and earnings from my SUSORP
account, I am not a RETIREE of a state-administered retirement program.
Member Signature (sign in the presence of a notary):
Notary: State of ______________, County of ___________________. The above named person who has sworn to and
subscribed before me this _____ day of ___________, ______, and who is personally known
or produced
__________________________________________identification.
___________________________________________
________________________________________________
Signature of Notary Public - State of _____________
Print, Type or Stamp Commissioned Name of Notary Public
III. Employer Certification:
This is to certify that the above named member was employed by this agency and will terminate, or has terminated on
_______________________.
Agency Authorized Signature:
Date signed:
Agency Name/Number:
Agency Phone:
IV. Division of Retirement Certification:
Termination verified
Yes
No
By: _________________________________________
Date: ___________________________
Rule 60U-1.012, F.A.C.
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