State of Connecticut

Attachment to:

Public Act No. 03-138 Memo

Municipal Employees Retirement System (MERS)
Retirement Credit Purchase Request Pursuant to Public Act No. 03-138

Purchase Description: All or part of the member's prior (non-MERS) municipal service may be purchased for credit in the MERS if the former municipal employer declines to voluntarily transfer the entire amount paid into such municipal fund by the employer and the employee, the funds still reside with the former employer, and the member will not receive credit for the same period of service from the former retirement system or any other source.

Purchase Cost: Either 2 % or 5%, as applicable, on the salary for the period of the former service and the actuarial cost necessary to fund the increased benefits payable by reason of such purchase plus interest at the rate of 6 %, compounded annually on such payment. The purchase cost will be based on an assumed retirement date. If the member's actual retirement effective date differs from the date used to compute the initial purchase cost, an adjustment will be made at the time of the member's retirement. If there is an increase in the cost, no credit will be given in the MERS pension calculation until full payment is made; if there is a cost decrease, the member will be refunded the difference in cost.

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Member's Information (Please print)

Member's Name: _________________________________________ Social Security Number:_________________
Member's Mailing Address:______________________________________________________________________
Current Municipal Employer:_____________________________________________________________________
Employer's Address: ___________________________________________ Telephone Number:_________________

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Member's Statement

I wish to purchase my former service from _________________ through ________________ while I was employed by
_______________________________________________ for credit in the MERS. I hereby certify that I have not
(Name of Former Municipality)
received a refund of the retirement contributions I made during that time and I will not receive a pension based on this employment period from such former employer or any other source.
__________________________________________ _______________________________________
Member's Signature Date

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Former Employer's Vertification

Name of Pension Plan: __________________________________________________________________________
Date of Hire: ____________ Date of Termination: _____________ Plan: Contributory ____or Non-Contributory____
(Please check one)
Did this former employee receive a refund of his/her retirement contributions to your plan? Yes _______  No ______
(Please check one)
Is this former employee entitled to any benefits from your municipal retirement plan? Yes________ No_______
(Please check one)
Total wages earned during employment period the member wishes to purchase: $_____________________________
I hereby certify that to the best of my knowledge the information contained herein is correct.
_________________________________ _____________________ __________________ _________________
Authorized Municipal Signature Title Telephone Number Date

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Please return the completed form to: Retirement & Benefit Services Division, Municipal Employees Retirement System Unit, 55 Elm Street, Hartford, CT 06106, Attention: Rudy Nelson. Questions regarding the completion of this form may be directed to the MERS Unit at (860) 702-3500.

New - 10/2003

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