Florida Retirement System Pension Plan
Request For Refund of Employee Contributions
PO BOX 9000
Tallahassee, FL 32315-9000
Local Phone: 850-907-6500 Toll Free: 844-377-1888 Fax: 850-410-2010
Rule 60S-4.009 , F.A.C.
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MEMBER INFORMATION (please type or print):
MEMBER NAME:_________________________________________ MEMBER SSN:____________________
(First, Middle, Last Name)
DATE OF BIRTH :___________ DAYTIME PHONE:(_____)_____________ E-MAIL:____________________
(Street; including apartment) (City) (State) (Zip Code)
List your last date of employment with any Florida Retirement System (FRS) employer: __________________
List all employers you worked for within the last 3 months. In addition to FRS-covered employment, work
includes, but is not limited to part-time work, temporary work, other personal services (OPS), substitute
teaching, adjunct instructing or non-Division approved contractual services: ____________________________
IMPORTANT INFORMATION ABOUT REFUNDING EMPLOYEE CONTRIBUTIONS
1. To be eligible to receive a refund of your employee contributions you must terminate employment from all FRS
participating employers and remain off payroll with all FRS-participating employers for three complete calendar
months following your employment termination date. See list above for examples of employment with FRS
participating employers. If your FRS employer reports your position for retirement purposes, your employer
must also report your employment termination date to the FRS. For example: If you terminate your
employment July 6
, the earliest you may receive a refund of employee contributions is during the month of
2. A refund of your accumulated employee contributions cancels the service credit represented by the
contributions. By receiving a refund, you waive all rights under the FRS (or other existing systems administered
by the FRS) to the service credit represented by refunded contributions.
3. Your non-employee contributory FRS service credit (if applicable) will not be affected by this refund.
4. If you are vested in the FRS Pension Plan your employee contributions can be left on deposit and qualify for
a future monthly retirement benefit.
5. Refunding employee contributions may have serious tax implications. Read the enclosed Special Tax Notice
Regarding Plan Payments for additional information and consult a tax professional if you have questions.
By signing this form, I am requesting a refund of all employee contributions and I acknowledge that I have
read and understand the above information.
MEMBER SIGNATURE: ___________________________________________ DATE: ________________
Return the completed form to the address or fax number listed above.