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The employee completes parts A and B of this form and submits it to the employer where the member rendered the service to purchase. If the employer participated in a multi-employer public retirement system, it is advisable to send this form directly to that retirement system. The employer should then return this form to the employee before the completed form is submitted to ETF.

If you would like to complete the form electronically, be sure to first download the form, complete using Acrobat Reader, and save.

Submit the completed form to your employer.

Note: ETF is unable to assist with Adobe Acrobat Reader technical or compatibility issues. If you need assistance, please visit Adobe’s help site.