Form # 220 -Request To Establish Reciprocal Service Credit

ADVERTISEMENT

Form # 220
Revised 7/2015
1400 West Third, Little Rock, AR 72201
Phone (501) 682-1517 or (800) 666-2877
Fax: (501) 682-1812
Website:
Request to Establish Reciprocal Service Credit
Member Information
Member's Name___________________________________________________SSN________________________________
Mailing Address_______________________________________________________________________________________
City _________________________________
State ______________________________
Zip _____________________
Telephone Number (____) _________________________ Email Address ________________________________________
I request that ATRS credit the service from my employment covered by a reciprocal retirement system under ACA
§ 24-2-401 et. seq. or an alternate retirement plan authorized under Arkansas law. All requests for reciprocal
service credit are subject to verification that the service meets eligibility requirements for reciprocal credit and is
subject to verification with your participating employer and the reciprocal system or plan in which the service
accrued. If you have credit with more than one reciprocal system, submit this form for each reciprocal plan for
which you are requesting credit to ATRS.
Name of Reciprocal System or Alternate Plan_____________________________________________________
(APERS, ASHERS, State Police, Local Fire & Police, Judicial, or alternate retirement plan)
Member’s Signature _______________________________________________ Date______________________
Certification of Reciprocal Systems
The above member is/was a member of__________________________________________________________
Member has established service credit of ___________ for the period from ___________ to ____________
Years/Months
Date
Date
As an employee of ____________________________________________________________________________
____________________________________________
______________________
____________
Retirement System Representative Signature
Telephone Number
Date
To be filled out by Arkansas Teacher Retirement System
Member has established service credit of ___________ for the period from ___________ to ____________
Years/Months
Date
Date
As an employee of ____________________________________________________________________________
____________________________________________
______________________
____________
Retirement System Representative Signature
Telephone Number
Date
Alternate Plan Administrators:
Has the member received a full or partial refund of contributions or an account distribution? □ Yes □ No
Plan Name ____________________________________________________________________________
____________________________________________
______________________
____________
Alternate Plan Administrator Signature
Telephone Number
Date

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Request To Establish Or Revise A Non-contracted Provider Record Request To Establish Or Revise A Non-contracted Provider Record Business
Form 5010 - Certificate To Establish Out-of-state Delivery Of Motor Vehicle To Nonresident - Arizona Department Of Revenue Form 5010 - Certificate To Establish Out-of-state Delivery Of Motor Vehicle To Nonresident - Arizona Department Of Revenue Financial
Form D - Request To Transfer Issue To A Group Appeal - Department Of Health & Human Services - Provider Reimbursement Review Board Form D - Request To Transfer Issue To A Group Appeal - Department Of Health & Human Services - Provider Reimbursement Review Board Legal
Form 2305 - Affidavit To Establish Title To Exempt Property Form 2305 - Affidavit To Establish Title To Exempt Property Financial
Form 31 - Request For Special Reciprocal Reduction Of Fees Between Iupui And Puwl Form - Purdue University Form 31 - Request For Special Reciprocal Reduction Of Fees Between Iupui And Puwl Form - Purdue University Education
Form 2448 - Taxpayer's Request To Move An Eft Credit Form 2448 - Taxpayer's Request To Move An Eft Credit Financial
Form 911 - Request For Taxpayer Advocate Service Assistance - Department Of The Treasury - 2015 Form 911 - Request For Taxpayer Advocate Service Assistance - Department Of The Treasury - 2015 Financial
Form 911 - Request For Taxpayer Advocate Service Assistance (and Application For Taxpayer Assistance Order) Form 911 - Request For Taxpayer Advocate Service Assistance (and Application For Taxpayer Assistance Order) Financial
Form 911 - Request For Taxpayer Advocate Service Assistance Form 911 - Request For Taxpayer Advocate Service Assistance Financial
Form Rs 5509 - Application For Military Service Credit Under Article 20-rssl Form Rs 5509 - Application For Military Service Credit Under Article 20-rssl Legal

Related Categories

Parent category: Legal
Download
Go