GERS_Authorization_of_Payroll_Deduction_for_Non-Credited_Service_Time
AUTHORIZATION OF PAYROLL DEDUCTION FOR NON-CREDITED SERVICE TIME Please check one or more of the following that apply and complete the information: I hereby authorize GERS to start payroll deduction for payment of my non-credited service time effective from ________ – ________ – ___________ for the amount of $ ____________________________________________ mm dd yyyy (Enter the bi-weekly deduction amount - not less than minimum amount) to pay off my prior service balance of $ ______________________. (Enter total contributions due) I hereby authorize GERS to change payroll deduction for payment of my non-credited service time effective from _______ – _______ – _______ from $ __________________________ to $_______________________________ mm dd yyyy (Enter the previous bi-weekly (Enter the bi-weekly deduction amount - deduction amount) not less than minimum amount) to pay off my prior service balance of $ __________________________. …
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AUTHORIZATION OF PAYROLL DEDUCTION FOR NON-CREDITED SERVICE TIME Please check one or more of the following that apply and complete the information: I hereby authorize GERS to start payroll deduction for payment of my non-credited service time effective from ________ – ________ – ___________ for the amount of $ ____________________________________________ mm dd yyyy (Enter the bi-weekly deduction amount - not less than minimum amount) to pay off my prior service balance of $ ______________________. (Enter total contributions due) I hereby authorize GERS to change payroll deduction for payment of my non-credited service time effective from _______ – _______ – _______ from $ __________________________ to $_______________________________ mm dd yyyy (Enter the previous bi-weekly (Enter the bi-weekly deduction amount - deduction amount) not less than minimum amount) to pay off my prior service balance of $ __________________________. (Enter total contributions due) I hereby enclose the following payment(s) for my non-credited service time to pay off my prior service balance of $ _____________________________ (Enter total contributions due) Certified Check / Money Order No. Amount ____________________________________________ _____________________________ ____________________________________________ _____________________________ ____________________________________________ _____________________________ ____________________________________________ _____________________________ ____________________________________________ _____________________________ ____________________________________________ _____________________________ Name in Full: __________________________________________ Signature: ____________________________________________ Social Security No: ___________ – ________ – _____________ Department: __________________________________________ Employee No.: _________________________________________ GERS-BEN111 REV 06 Internal Use Only Date Received: _____________ Date Submitted: ____________ GOVERNMENT EMPLOYEES RETIREMENT SYSTEM 3438 Kronprindsens Gade, GERS Complex - STE 1, St. Thomas, VI 00802-5750 • (340) 776-7703 • Fax (340) 776-4499 3005 Orange Grove, Lot #5, Christiansted, St. Croix, VI 00820-4313 • (340) 773-5480 • Fax (340) 773-5497