THE COMMONWEALTH OF MASSACHUSETTS
State Board of Retirement
BUYBACK
REQUEST FORM
Full Name Social Security Number
If You Worked Under Another Name, Please Advise Retirement Date if Applicable
Home Address (Number and Street and/or P.O. Box
City or Town/State/Zip Telephone Number (Home OR Cell)
Agency Where You are Currently Employed Start Date
Work Telephone Number E-Mail Address if Applicable
SERVICE YOU WISH TO PURCHASE
Agency Where Employed Dates of Service: Was This Service Refunded?
____/____/____to____/____/____ a Yes a No
____/____/____to____/____/____ a
Yes a No
____/____/____to____/____/____ a Yes a No
____/____/____to____/____/____ a Yes a No
____/____/____to____/____/____ a Yes a No
TWO-YEAR RULE
Please note, if you are purchasing creditable service you previously withdrew and refunded, or you rolled over the funds
to another retirement plan, you may be required to satisfy certain service requirements before you can be eligible for
particular retirement bene ts. If the above applies to you, and unless you meet one of the applicable exceptions, you
would not be eligible to receive a retirement allowance until you have been in active membership service for at least two
consecutive years following the start of your new employment with the Commonwealth. We recommend you contact the
Board to determine if this applies to you and to review the applicable exceptions.
I understand that the State Retirement Board will review this request to determine whether the above service may be purchased
pursuant to M.G.L. c. 32 and applicable Board rules and policy.
Signature Date
PLEASE RETURN COMPLETED FORM TO:
For More Information call (617) 367-7770 or 1-800-392-6014 (Mass only)
www.mass.gov/retirement
PLEASE COMPLETE THIS FORM TO PURCHASE SERVICE (PLEASE PRINT)
09/2010
*BUYBACK REQUEST*
State Retirement Board, One Winter Street, 8th Floor, Boston, MA 02108
