Submit completed form to: - County Employees` Retirement Fund

Version 5.3
Submit completed form to:
County Employees' Retirement Fund
2121 Schotthill Woods Drive
Jefferson City, MO 65101
Toll Free: 877-632-2373
Fax: 573-761-4404
FORM 5
SPECIAL CONSULTANT
The County Clerk and participant complete this form upon a full-time employee’s termination of employment between January 1, 1990 and
August 27, 1994.
CONSULTANT INFORMATION
–
Social Security Number
–
First Name
County of Employment
Initial
Last Name
Address
Suffix
City
Work Phone
Gender
(
Male
)
State
Home Phone/Cell
Female
Original Date of Hire
/
Marital Status
/
Married
CERF Eligibility Date
Single
/
(
)
Date of Birth
/
Zip
/
LAGERS
/
Non-LAGERS
Note: In some cases the Original Date of Hire precedes the CERF Eligibility Date.
If Original Date of Hire and CERF Eligibility Date are different, please explain
Date of Termination______________________________________
FINAL COMPENSATION INFORMATION
Submit figures for final compensation. The average final compensation is calculated using the participant’s two highest calendar years of
compensation.
1.
$
For the calendar year of
2.
$
For the calendar year of
REQUIRED SIGNATURES
I hereby elect to be employed as a special consultant to the County Employees’ Retirement Fund (CERF). As such, I agree to be available to provide opinions on
the problems of retirement to the Board of Directors of CERF upon their request. I understand that by making this election, I must pay 50% of the total buyback
amount to participate. The Plan Administrator will bill me upon verification of my application. The other 50% of the total buyback amount may be deducted from
my annuity payments in any manner acceptable by the provisions of the plan (CERF), or I may pay the full amount (100%) in one lump sum instead.
I understand that I will be notified upon verification of this information as to the buyback amount and retirement benefit calculations. Any misrepresentation of fact
will result in an adjustment of benefits and/or appropriate legal action.
Signature of Consultant
Date
I hereby certify that the information with regard to the employment status and any prior service dates for the applicant in this county is correct. Attached to this
form are copies of the employee’s documentation of county income.*
Signature of County Clerk
Date
* ACCEPTABLE DOCUMENTATION OF COUNTY INCOME




W-2s. If the W-2s do not reflect gross wages, a printout from county payroll records must accompany the W-2s, along with an explanation of any
difference.
A federal tax return (Form 1040) with supporting W-2s.
A printout from County payroll records, accompanied by the Clerk’s certification and seal.
Other supporting documentation as approved by the Board of Directors.
Form5 Special Consultant rev0616
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