Patrol Plan Member Verification of Service Request Form
Per Nebraska statute, service credit is earned for service rendered while a contributing member of the Patrol Plan, rounded to
the nearest month. NPERS will grant one year of service credit for each full year that elapses from a Trooper’s plan entry
date. NPERS will grant partial service credit if a Trooper contributes to the Patrol Plan for only part of a year or terminates
employment before the anniversary of the Trooper’s plan entry date.
NPERS CANNOT grant service credit for periods when a Trooper does not make retirement contributions. Service credit is
not granted if a Trooper goes on a leave of absence, takes leave without pay, is placed on unpaid suspension, is paid
worker’s compensation benefits, or incurs any other periods when they are not contributing to the plan.
A Trooper may submit this form to make a one-time request for a tentative verification of service from NPERS up to one year
but no less than 180 days prior to retirement or entering DROP. When making the request, the Trooper is required to disclose
any periods where the Trooper was not contributing to the plan.
Declaration of Non-Contributing Periods
Answer all of the questions below. Failure to fully and completely answer the questions may result in your service credit being
misstated. This could negatively affect your retirement eligibility date and/or the amount of your retirement benefit. You may
estimate any leave without pay dates. NPERS will contact the Patrol Business office to confirm the actual dates.
1. On what day did you become a sworn officer with the Nebraska State Patrol?_______________________
2. Did you have any periods of leave without pay during your employment with the State Patrol? Yes No
If “Yes”, please check all that apply:
I had no available leave time
I received worker’s compensation benefits for certain period(s)
Qualified Military Service – no leave time used during all or part
Suspension without pay
Other periods where I did not contribute to retirement
3. If you checked “Yes” for question 2, please list the approximate dates and describe the reason(s) why you were not
receiving pay from the State Patrol:_________________________________________________________________
4. Estimate the total number of leave without pay services hours attributable to question 2:_______________________
Request for Verification of Service
I am making my one-time, written request for a tentative verification of my service.
I understand any periods where I was not contributing to retirement could negatively impact my retirement eligibility date
and/or the amount of my retirement benefit.
I understand NPERS will corroborate the information I reported on this form with the State Patrol Business Office.
I understand all future service and non-contributing periods will be reviewed by NPERS when I submit my application for
retirement and may impact my eligibility for and/or the amount of my retirement benefit.
I certify I am making this request up to one year but no less than 180 days prior to my anticipated retirement date or
DROP entry date.
I certify the information submitted on this form is true, correct, accurate, and complete to the best of my knowledge.
Member’s Signature:_________________________________________________________ Date: _______________________________
