Rev. 04/2010
I understand that as a member of the Richmond Retirement System:
I hereby elect the following action regarding my accrued sick leave:
Processed Date:
Review Date:
Address:
Name: SSN:
Department:
DEFERRED RETIREMENT OPTION PROGRAM (DROP)
ELECTION OF SICK LEAVE BENEFITS
please type or print in ink
PART A: MEMBER INFORMATION
leave as of __________________ .
Department:
City: State:
• I will continue to accrue additional sick leave during my DROP period.
To convert ___________ hours of my unused sick leave to creditable service.
(Date of Entry into the DROP)
Date:Member's Signature:
Zip Code:
DROP Entry Date:
• I may not change this election after my DROP entry date.
To convert all hours of my unused sick leave to creditable service, or
PART B: ELECTION OF SICK LEAVE BENEFITS
PART C: DEPARTMENT CERTIFICATION OF UNUSED SICK LEAVE
RRS USE ONLY
Reviewed By:Processed By:
Date:
Date:
Payroll Technician Signature:
Agency/Department Head Signature:
This is to certify that ________________________________ had ________________ total hours of unused sick
Position:
• I may elect to convert any or all of my unused sick leave to creditable service upon my entry into the DROP pursuant to the
provisions of Chapter 78 of the Retirement Code.
• If I elect to retain part of my unused sick leave during my DROP period, any unused sick leave remaining at the end of the DROP
period will not be eligible for conversion.
900 East Broad Street
Room 400
Richmond, VA 23219
RICHMOND RETIREMENT SYSTEM
www.richmondgov.com/retirement
Phone 804.646.5958
Fax 804.646.5299
