Application To Purchase IPERS Service Credit
Application To Purchase IPERS Service Credit
Application To Purchase IPERS Service Credit
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<strong>To</strong> the ApplicantOnce you receive this application back, please review it for accuracy and completeness*. If theapplication is complete, return it to <strong>IPERS</strong> 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 <strong>IPERS</strong> 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 <strong>IPERS</strong> postmarkedon or before the date indicated on the notification of cost letter that will be mailed to me after my application has been approved by<strong>IPERS</strong>.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