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Application For Creditable Service Due To Period Of Active Duty Military Service Form - Police Retirement System - Kansas City, Missouri Page 2

To Apply:

Step 1: Upon your return to service with the Police Department, request a Military Leave of Absence

worksheet from the Retirement System of the amount of creditable service affected by your period of

unpaid leave and the amount of member contributions you would have made during that time period.

Step 2: Submit this completed application along with the required documentation directly to the

Benefits Coordinator at the Retirement System.

Step 3: Your application will be reviewed by the Military Leave Review Committee which will forward

a recommendation to the Retirement Board. You will be notified of the Retirement Board’s decision.

Once notified, you will have three times the period of military service, but not to exceed five years, in

which to make the required member contributions, if applicable.

____________________________________________________________________________________________________________

This Section to be Completed by Retirement System Staff

Previously granted at member contribution cost: _____ Years _____ Months _____ Days

Previously granted with waived contributions: _____ Years _____ Months _____ Days

Current Request: Based on review of documentation submitted and in accordance with subsection 3 of

section 86.1110 RSMo. or subsection 3 of section 86.1500 RSMo. and Retirement Board Policy # 010:

Creditable service to be granted at member contribution rate:

_____Years _____ Months _____Days

Required member contributions $ ________

Creditable service to be granted with waived contributions:

_____ Years _____ Months _____ Days

Member contributions waived $ _________

Recommendation of Military Leave Review Committee

_____ Approve

Date: ___________________

_____Not Approve

Reason: _______________________________________________

________________________________________________________________________

Approved by Retirement Board

Signed: _______________________________________ Date: ____________________

Retirement Board Secretary

Required member contributions of $ _____________ must be paid in full no later than

______________ before creditable service at member contribution rate will be granted.

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Application For Creditable Service Due To Period Of Active Duty Military Service Form - Police Retirement System - Kansas City, Missouri Page 2