Application To Purchase IPERS Service Credit

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