PRINT ALL INFORMATION Certification of Continued Employment After DROP - PDF document

1 PRINT ALL INFORMATION Certification of C
PRINT ALL INFORMATION Certification of Continued Employment After DROP ParticipationP.O. Box 44213, Baton Rouge, LA 70804-4213 225.922.0600 · Toll-Free 1.800.256.3000 Form 9-02A R052016 Today's Date Last Name Middle Name Member's First NameIMPORTANT: Complete the entire form. Follow the specific instructions for each section. All dates should be in MM/DD/YYYY format. SECTION 1: MEMBER'S INFORMATION Zip Code State City Member's Mailing Address Daytime Area Code/Phone Number Member's Birth Date Evening Area Code/Phone Number Email Address 9-02A R052016 RETAIN A COPY FOR YOUR RECORDS DROPCONT Page 1 of 1 SECTION 2: MEMBER SIGNATURE Social Security Number Date Member's Signature SECTION 3: AGENCY CERTIFICATION Ending Date of DROP ParticipationI hereby certify that I plan to continue state employment at the end of my DROP participation period. I understand that employee and employer contributions will resume being paid to the retirement system. I also understand that the funds in my DROP account cannot be withdrawn until I terminate state employment.This is to certify that the above mentioned employee is continuing state employment at the end of their DROP participation period and employee and employer contributions will resume. Daytime Area Code/Phone Number Date Signature of Personnel Officer Personnel Officer Email Address Title Name of Agency Name of Personnel Officer Agency 3 digit Number