Opers Form F 111C – Fill Out and Use This PDF

Ohio Public Employees Retirement System

277 East Town Street, Columbus, Ohio 43215-4642
1-888-400-0965 www.opers.org	*F-111C*

Early Retirement Incentive Plan

Employee and Employer’s Agreement

•Submit this Agreement to OPERS no later than 45 days before the employee’s effective benefit date or the termination date of the plan, whichever is earlier, to avoid processing delays and late payment to OPERS.

•If any of the dates in Section 3 - ERI Plan Information change after this Agreement is filed with OPERS, a new Agreement must be submitted. If you have already been billed, the cost may change. OPERS will send you a revised cost, if applicable.

Section 1 - Employee Information

Date of Birth

Social Security Number

Month

Day

Year

First Name

MI Last Name

Street or Mailing Address

Apt. Number

City

State

ZIP Code

-

Home Phone Number

Work Phone Number

Cell Phone Number

E-mail Address

Fiscal Officer Reporting to OPERS First Name

MI Last Name

F-111c (01/13)

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Section 3 - ERI Plan Information

Month Day Year

Employee’s last day of employment

This date must be the last day for which compensation was paid to the employee and must not be prior to the signature date.

Month Day Year

Payment to be made either in one payment or by a first installment on

This date must be the last day of the month before the employee’s benefit effective date or the termination date of the plan, whichever is earlier.

Month Day Year

Employee’s effective benefit date

This date must be the first day of a month and the employee must not receive compensation for service on or after this date.

Section 4 - Employee and Employer’s Agreement

The undersigned agree that the employee listed in Section 1 of this Agreement is eligible to retire with an age and service retirement benefit from OPERS, or will qualify to retire with the purchase of service credit under the retirement incentive plan adopted per Section 145.297 or 145.298, Ohio Revised Code.

Further, it is agreed that the employer will make payment and the employee will retire on the specified dates as indicated in Section 3.

The employee understands that if he/she dies prior to his/her effective benefit date, then this Agreement is cancelled. The employee authorizes release of necessary account information by OPERS to the employer in connection with the retirement incentive plan.

The employer requests certification of the total cost of purchasing service credit for the above-named employee under its retirement incentive plan which provides for a maximum amount of service purchasable as indicated in Section 3. By signing this Agreement, the employer accepts liability for the service credit to be purchased and the employee agrees to retire.

	Today’s Date
Employee	Month			Day			Year
Signature__________________________________________________________________________________
Do not print or type name
	Today’s Date
Fiscal Officer Reporting to OPERS	Month			Day			Year
Signature__________________________________________________________________________________
Do not print or type name
Subordinate	Today’s Date
	Month			Day			Year
Signature
(if applicable)________________________________________________________________________________
Do not print or type name

F-111c (01/13)

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