Fillable INFORMATION FROM FORMER MEMBER

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INFORMATION FROM FORMER MEMBER

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BUY-BACK CALCULATION REQUEST: AB 2766
Type or print in ink.
INFORMATION FROM FORMER MEMBER
FIRST NAME:
MI:
LAST NAME:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
MAILING ADDRESS:
STATE:
ZIP CODE:
HOME PHONE:
CELL PHONE:
EMAIL ADDRESS:
CURRENT PUBLIC RETIREMENT SYSTEM:
CURRENT PUBLIC EMPLOYER:
HIRE DATE/CURRENT EMPLOYER:
SUMMARY OF LEGISLATION
Approved by the Governor on September 25, 2002, Assembly Bill 2766 (AB2766) added new statutes to
the California Government Code. These statutes allow former safety members, who are members of a
reciprocal retirement system, to redeposit their contributions upon meeting certain criteria.
Government Code §31831.3
(e) This section shall only apply to the following:
(1)
A
former member who is in the service of an employer as an officer or employee of a law
enforcement agency or fire department whose principle duties consist of active law enforcement or
firefighting and prevention service, but excluding one whose principle duties are those of tel
ephone
oper
ator, clerk, stenographer, machinist, mechanic, or otherwise, and whose functions do not
clearly come within the scope of active law enforcement or firefighting and prevention service, even
though the officer or employee is subject to occasional call, or is occasionally called upon, to
perform duties within the scope of active law enforcement or firefighting and prevention service.
(2)
A
former member who is in the service of an employer and seeks to redeposit contributions as
an officer or employee of a law enforcement agency or fire department in this system whos
e
pr
inciple duties consisted of active law enforcement for firefighting and prevention service, but
excluding one whose principle duties are those of telephone operator, clerk, stenographer,
machinist, mechanic, or otherwise, and whose functions do not clearly come within the scope of
active law enforcement or firefighting and prevention service, even though the officer or employ
ee
i
s subject to occasional call, or is occasionally called upon, to perform duties within the scope of
active law enforcement or firefighting and prevention service.
ACKNOWLEDGEMENT & AUTHORIZATION
Under penalty of perjury, I declare that I am an active member of a reciprocal public retirement system and the above
government code sections apply. I have not purchased this service credit from another retirement system. I authorize my
current employer and current retirement plan administrator to release any service purchase or redeposit records requested
by StanCERA.
I understand requests take 8-12 months to be processed.
Signature:
Date:
CLEAR FORM
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INFORMATION FROM FORMER MEMBER

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Completed 1 January 2021

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