GERS_Prior_Service_Form
PRIOR SERVICE FORM (Please print all information on form.) DATE: ________________________________________ I, ___________________________________________________, hereby request information as to the amount of service time that I have accrued with the Virgin Islands Government. I estimate my years of service to be __________________. Date of Birth _________—__________—_________________ Age ___________________ (mm) (dd) (yyyy) What is the purpose of this request? K For repayment of contributions K I'm eligible for retirement If eligible for retirement, what is your projected retirement date?_____________________________________________ I HAVE WORKED IN THE FOLLOWING DEPARTMENTS: (If you need additional space kindly attach a separate sheet.) DEPARTMENT POSITION TITLE PERIOD OF SERVICE Military Time _______________________________________________________________________________________ _____________________________________________ Employee No. ________________________________ Signature of Member Social Security No. …
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PRIOR SERVICE FORM (Please print all information on form.) DATE: ________________________________________ I, ___________________________________________________, hereby request information as to the amount of service time that I have accrued with the Virgin Islands Government. I estimate my years of service to be __________________. Date of Birth _________—__________—_________________ Age ___________________ (mm) (dd) (yyyy) What is the purpose of this request? K For repayment of contributions K I'm eligible for retirement If eligible for retirement, what is your projected retirement date?_____________________________________________ I HAVE WORKED IN THE FOLLOWING DEPARTMENTS: (If you need additional space kindly attach a separate sheet.) DEPARTMENT POSITION TITLE PERIOD OF SERVICE Military Time _______________________________________________________________________________________ _____________________________________________ Employee No. ________________________________ Signature of Member Social Security No. ____________________________ Telephone No.________________________________ Mailing Address _____________________________________________________________________________________ _____________________________________________________________________________________ GERS-BEN107 Rev 06 (Print Name) 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