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APPLICATION FOR REFUND OF ERRONEOUS CONTRIBUTIONS TO: BOARD OF TRUSTEES EMPLOYEES RETIREMENT SYSTEM OF THE GOVERNMENT OF THE VIRGIN ISLANDS I hereby request a refund of Erroneous Contributions made by me as a member of the Employees Retirement System of the Government of the Virgin Islands under and in pursuance of the provisions of Title 3 of the Virgin Islands Code. In connection with this request, I, __________________________________________________, declare that I am entitled to such refund by reason of Erroneous Deduction. My title is ________________________________________________ at the Department of _____________________________________ on the island of _____________________________ . Effective date of Erroneous Deductions ________–________–____________ SSN _______________________________ (mm) (dd) (yyyy) Employee No. ___________________________ Telephone No. ____________________________ Gender_____________ I hereby represent that I have no other claims against the Employees Retirement System of the Government of the Virgin Islands except as herein stated, and the acceptance of this refund by me shall operate as a release of any claims which I may have against the said System of all kinds and my own free will and accord. I further declare that I have read and understand this application and am signing the same of my own free will and accord. Date of Birth _________—__________—_________________ ____________________________________________ (mm) (dd) (yyyy) (Print Name of Member) ________________________________________________ ____________________________________________ (Witness) (Signature of Member) Physical Address _________________________________ Mailing Address _______________________________ ________________________________________________ _____________________________________________ City State Zip City State Zip Date of Application _________—__________—_________________ (mm) (dd) (yyyy) Note: Refunds cannot be processed until six weeks after the end of the Quarter in which the applicant receives his/her final regular salary payment. A refund is payable to members only upon withdrawal from service, which means under the Act "complete severance of employment of a member as an employee of the employer, by resignation, discharge, dismissal or death" or in the case of erroneous deductions. (Print Name) GERS-BEN103 REV 06 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 (Select a value) (Select a valu