Fillable Buy Back Calculation Request

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Buy Back Calculation Request

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The Buy Back Calculation Request form is 1 page long and contains:

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  • 5 check-boxes
  • 21 other fields

Country of origin: OTHERS
File type: PDF

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BUY-BACK CALCULATION REQUEST
Type or print in ink.
FIRST NAME:
MI:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
MAILING ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME PHONE:
CELL PHONE:
EMAIL ADDRESS:
EMPLOYER:
DEPARTMENT:
EMPLOYEE ID
SERVICE TIME REQUESTED
Medical Leave, includes SDI, On the Job Injury, Worker’s Comp or FMLA (limited to 2080 hours per incident)
Dates:
Prior Full-Time Service
(Previously refunded)
Dates:
Prior Part-Time Service
Dates:
Active Military Time (Tiers 1& 4 Only)
– Attach copy of DD214 and letter from Veteran’s Office
Dates:
Other Public Service Outside of StanCERA (Tiers 1 & 4 Only)
Attach letter as proof of service and ineligibility of benefits and indicate dates/hours worked,
refund of contributions, and no entitlement of monthly benefit for specified dates.
Agency Name:
Employment Dates:
SIGNATURE
Please allow 8-12 months for calculations to be processed. Repeat requests from previously calculated service will
only be accepted 6 months from the mailing date of the prior contract from contract for same service, no
exceptions.
Buy
-Back Contracts are sent via U.S. Mail and are time sensitive. You will be granted 30 days to schedule an
appointment with a Member and Employer Services Specialist to initiate a permissive service purchase contract.
Signature:
Date:
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Buy Back Calculation Request

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Completed 1 January 2021

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