Application To Purchase IPERS Service Credit

Application To Purchase IPERS Service CreditBased upon:JJJPublic Employment in Another State of the United StatesFederal Government EmploymentPublic Employment covered under Other Public Retirement Systems within IowaThe information provided in this application will help you determine if you qualify topurchase IPERS service credit based upon other public employment. The other publicemployment must be comparable to IPERS covered employment. Your care infollowing the instructions and providing IPERS with complete information will assureproper processing should you decide to proceed with the purchase of such credit. Thecompletion of this application puts you under no obligation to purchase this credit.Please allow 4-6 weeks for processing.IOWA PUBLIC EMPLOYEES' RETIREMENT SYSTEM7401 Register Drive ▲ PO Box 9117 ▲ Des Moines IA 50306-9117800-622-3849 ▲ Local 515-281-0020FAX: 515-281-0053 ▲ E-mail: info@ipers.org ▲ Web Site: www.ipers.org15.01 November 05, 2003

Am I qualified to purchase time into IPERS?1. You must be a vested or retired member of IPERS with at least one full calendar year of covered wages on file.2. You must have been a public employee. This includes members who had service as a public employee in another stateor the federal government comparable to IPERS’ covered employment, or public employment coverage under otherretirement systems established within Iowa.Can my years of service be purchased in increments?You may purchase service credit for your other public employment in a lump sum or in increments of one or more calendarquarters. However, your service purchase costs for other public employment and other types of permissive service creditcannot exceed $40,000 in a calendar year. If you wish to purchase only part of the service from the other public system andthe other public system allows for partial withdrawals, you may purchase that portion of service.What if I am still eligible for a benefit from another public retirement system?If you are eligible for a benefit from another public retirement system, you must waive all rights for the service you wish topurchase under the other system. The other public retirement system must accept the waiver for it to be valid. Beforereceiving credit for years of service in the other public system, the waiver must be on file with IPERS.Instructions for Completing the ApplicationPlease note you must submit this application for verification by each public employer in a given state or retirement system.There are three parts to this application. Please read the instructions below to ensure the application is completed correctlyby each appropriate person(s).Part 1 - to be completed by the applicant. After completing Part 1, you must forward an application to each of theapplicable former employers for completion of Part 2.Part 2 - to be completed by the reporting official for each of the other public employers where services were rendered.After completing Part 2, we ask that the former employer forward this application to that employer’s retirement system, ifapplicable. If not applicable, after completing Part 2, the employer should return the application to the applicant listed inPart 1.Part 3 - to be completed by an official of the retirement system in which the member named in this application was amember during the year(s) listed. After completing Part 3, the retirement system should return the application to theapplicant listed in Part 1.Page 2

To the ApplicantOnce you receive this application back, please review it for accuracy and completeness*. If theapplication is complete, return it to IPERS at the address indicated on the front of this application.Notification of the cost of your service purchase will arrive in the mail. If you are entitled to a state and/orfederal retirement benefit from another system, a waiver will be included with your cost letter. This waivermust be signed by you and your other public retirement system(s). This completed waiver mustaccompany or precede your payment.NAME:*Your application is not complete until you have included a separate application for each employer withina given state or other type of public employment.PART 1 - APPLICANTSOCIAL SECURITY NUMBER:ADDRESS:CITY, STATE, ZIP:PHONE NUMBER:What is your approximate date of retirement? ______________________________Beneficiary’s date of birth: ___________________ Is beneficiary your spouse? Yes _____ No _____Is your current position in a protection occupation? Yes _____ No _____ If yes, how many years? ___APPLICANT'S AFFIDAVIT1. I hereby make application for purchase of IPERS service credit based upon my public employment in another state, the federal government, orpublic employment coverage in another public retirement system within Iowa.2. I certify the periods listed below include all of my public employment in a given state or retirement system, or the federal government.(Remember: A separate application must be completed for each employer.)3. I understand that to purchase this credit, my payment and the completed waiver (if necessary) must be remitted to IPERS postmarkedon or before the date indicated on the notification of cost letter that will be mailed to me after my application has been approved byIPERS.PLEASE LIST YOUR EMPLOYER DURING THE PERIOD YOU WISH TO BUY IN.If you had more than one employer, request a separate application for each.EMPLOYER NAME ADDRESS DATES OF EMPLOYMENTBEGINNING AND ENDINGI affirm the statements contained in this application are correct to the best of my knowledge and belief.DATE:SIGNATURE OF APPLICANT:Page 3

PART 2 - EMPLOYERTo enable us to decide this individual's eligibility to purchase IPERS credit based on public employment, we request your cooperationin answering the following questions.CERTIFICATION REGARDING EMPLOYMENTEMPLOYERSTARTINGNAMEDATEMO/DAY/YRDATE OF FIRSTPAYCHECKMO/DAY/YRTERMINATIONDATEMO/DAY/YRDATE OF FINALPAYCHECKMO/DAY/YRYES NO1. Does this employment meet qualification #2 on page 2 of this application? _____ _____2. Were contributions made to a retirement system for this individual? _____ _____If contributions were made to a retirement system for this individual, please forward thisform to the retirement system to complete Part 3. Otherwise, please return to the applicantlisted in Part 1.3. Was the individual hired for PERMANENT ____ TEMPORARY ____ or OTHER ____ employment?If the employment was temporary, you must provide the total hours worked and the total wages paid in each calendar quarter.If the employment was other, please describe. You may attach an additional sheet.I certify that the records show the employee named in Part 1 was employed continuously during the time(s) shown. (Please attach anexplanation for any work that was not continuous.)DATE: PRINTED NAME OF REPORTING OFFICIAL: TITLE:PHONE NUMBER:SIGNATURE OF REPORTING OFFICIAL:PART 3 - OTHER RETIREMENT SYSTEMTo enable us to decide this individual's eligibility to purchase IPERS credit based on public employment covered by your system, werequest your cooperation in answering the following questions.YES NO1. Did this individual and/or a public employer make contributions to your system for the periods stated in Part 2? ____ ____If there were exceptions, note the time periods: _______________________________2. Is this person receiving or entitled to receive a benefit from your system based upon this service? ____ ____3. Does this person have credit in your system for other employment in another state? ____ ____If yes, please explain: _________________________________________________________4. Do your records indicate any periods of employment covered by your system omitted in Part 2? ____ ____If yes, what were the periods? ____________________________Who was the employer? ____________________________NAME OF SYSTEM:I certify the above information was based upon the official records of this system.PHONE NUMBER:ADDRESS:CITY: STATE: ZIP:PRINTED NAME OF OFFICIAL: TITLE: DATE:AUTHORIZED SIGNATURE OF OFFICIAL:PLEASE RETURN THIS APPLICATION TO THE APPLICANT LISTED IN PART 1.Page 4