Retirement Election Form

Retirement Election Form
Biographical Information
Name
First NameLast Name
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Other
Employee identification number
Hire Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Election
Choose only one.
I realize that I will not be able to change my election to participate in the state retirement system once my election period has expired, and that my election will be irrevocable while I am employed at The University of Akron in any capacity. A defined-contribution plan may be available to eligible employees. For more information about these programs and eligibility, contact your applicable retirement system.
Clear
I realize that by deciding to join in an ARP, I am giving up my entitlement to participate in the qualifying state retirement system while employed at The University of Akron in any position. I further understand that by deciding to participate in an ARP offered by a private plan provider, I will be permanently precluded from claiming or purchasing service credit or participating in other state retirement system plans for the duration of my ARP election.
Clear
Authorization
I thus certify the above-mentioned Section II choice. If I cease to be continuously employed or am subsequently employed full-time by another Ohio public institution of higher education in a position for which a retirement election is available, I understand that I will be able to make an election to participate in another ARPor Ohio public retirement system.
Signature
Clear
Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
ONLY FOR THE USE OF THE OFFICE OF HUMAN RESOURCES

Only for ARP Elections

Rows	Amount
Contributions from employees
Contributions from employer
Contributions from employers to the ARP provider
Date of the most recent payroll report containing employee contributions to the applicable state system

Applicable state system
Annual remuneration
Date the university/college received the election form
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
University/College
Employer Code
Should be Empty:

Retirement Election Form

Biographical Information

Election

Authorization

ONLY FOR THE USE OF THE OFFICE OF HUMAN RESOURCES