THE COMMONWEALTH OF MASSACHUSETTS
State Board of Retirement
E N , ,
CONTRACT SERVICE
BUYBACK FORM
(M.G.L. c. 32, § 4 (1) (s))
SECTION A To be completed by Member:
Please return form with Section A completed to the State Agency that employed Member for Contract Service.
Section B (on reverse) to be completed by the State Agency.
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Name:
Former Name
(if applicable)
:
Street Address:
City, State, Zip:
Home Phone Number:
Social Security Number:
CONTRACT SERVICE CRITERIA:
a. Are you a member in service of the State Employees’ Retirement System and
do you have at least ten (10) years of creditable service with the State?
❏
Yes
❏
No
b. Does the contract service you are looking to purchase immediately precede
membership in or re-entry into the State Retirement System?
❏
Yes
❏
No
c. Please report the name of the State agency that employed you
for the contract service you are looking to purchase:
d. Please report the approximate dates of the contract service
you are looking to purchase:
STATEMENT AND SIGNATURE BY MEMBER
I, the undersigned, certify under the penalties of perjury, that the above information is true and correct. I also
understand that once I receive notification from the Board that I am eligible to purchase contract service, I must
either make a lump sum payment or enter into an installment agreement within 180 days after the notice. If I fail
to do so, I am forfeiting my right to purchase this service and will not be rebilled at any time in the future.
CONTRACT SERVICE BUYBACK FORM
(side 1)
(Name of the State Agency)
(Signature—DO NOT PRINT YOUR NAME)
(Date)
to
