Employer Certification Of Public Service Form Page 3
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4RETIREMENT SYSTEM CERTIFICATION
OF PUBLIC SERVICE
Defined Benefit Plan Participants — Government and Nonteaching
Part 1 — Completed by Member
(Please see Certification Form Instructions)
Member’s name ___________________________________________________________ STRS Ohio account no.
___________________
or
Address _________________________________________________________________ Social Security no. (last four digits) ___________________
Street
________________________________________________________________________
City
State
ZIP code
Email address ____________________________________________________________ Phone (_________) ______________________________
Area code
Part 2 — Completed by Retirement System in Effect During Time of Service
(Please return form to member)
1. Was the applicant ever a member of your retirement system?
❏
❏
Yes
No If no, skip to number 4. If yes, please provide the information requested below.
Contributions made by
Dates of plan membership
Type of plan
(check one or both)
From
To
Defined
Defined
DB/DC
Non-
Optional
Mo
Da
Yr
Mo
Da
Yr
benefit
contribution
hybrid
contributory
retirement plan
Applicant
Employer
q
q
q
q
q
q
q
❏
❏
2. Has the member withdrawn (refunded) his/her account with your system?
Yes
No
If yes, please provide the following: Date withdrawn ___________________________
❏
❏
Source(s) of funds withdrawn (check all that apply):
Employee contributions
Employer contributions
❏
❏
If checking “employer contributions,” were 100% of those contributions refunded?
Yes
No
❏
❏
3. Is the member currently receiving or currently entitled to receive a retirement benefit from your system?
Yes
No
If no, are there any conditions under which the member would be entitled to receive a retirement benefit from your system in the future?
Please explain: ___________________________________________________________________________________________________
If yes, please describe the type of benefit:
❏
Monthly benefit
❏
Lump-sum benefit (not a refund). Date of payment ___________________________
❏
Lump sum is the actuarial present value of the future retirement benefits.
❏
Other. Please explain: _____________________________________________________________________________________
_____________________________________________________________________________________
4. I certify the above statements are true to the best of my knowledge.
Retirement system ____________________________________________________________________________________________________
Street address ________________________________________________________________________________________________________
City _________________________________________________________________ State ____________ ZIP code _____________________
Print name ____________________________________________________________ Date __________________________________________
Title _________________________________________________________________ Phone (_________) ______________________________
Area code
15-128c1, 12/15/200
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