This application must be completed by you and your former employer. This application must be filed with a new Enrollment Application for theRetirement System to which you are transferring unless you are already enrolled in that second system. Members transfering from PERS to TPAFor from TPAF to PERS cannot transfer more than three years of service in one retirement system that occurred during the same time as yourmembership in the other retirement system. All other members cannot transfer any service in one retirement system that occurred during the sametime as your membership in the other retirement system.
PART 1 — Check one:
Transfer to Teachers' Pension and Annuity Fund Transfer to State Police Retirement System Transfer to Public Employees' Retirement System Transfer to Police and Firemen's Retirement System Print Full Name _________________________________________________________ Address ______________________________________________________________________________________________________ Currently a member of the _______________________________________________________________________________________ Resigned, Was dismissed, ______________________________ from my position as ______________________________________ Date of termination (MM/DD/YY) ______________________________________________ NEW EMPLOYER ______________________________________________________________________________________________
I hereby apply for the transfer of my membership to the retirement system indicated above and authorize payment of the withdrawal
value of my account to be made to that system subject to the statutes, rules and regulations of that system. I understand that once
my Application for Interfund Transfer is submitted to the Division of Pensions and Benefits, I cannot change my decision to

Signature of Applicant ___________________________________________________ PART II — CERTIFICATION OF FORMER EMPLOYING AGENCY
CERTIFYING OFFICER: In order to avoid delay in honoring this transfer, your certification will be used to calculate the payment due.
I hereby certify that _________________________________________________ from this department, agency, or school district on _______________________________________. The last salary deduction was made on ___________________________________________ for _________________________________________. The employee's annual base salary prior to resignation/dismissal was $_____________________________________________________.
I further certify that the following deductions have been made from his / her salary during the last two quarterly periods endingwith the current quarter (see QUARTERLY REPORT OF CONTRIBUTION). Bi-weekly reporting agencies should attach ascreen print of TREADHOC biweekly certification with salary projected until termination date.
__________________________________________ ________________________________________________________________________________________________ SIGNATURE OF CERTIFYING OFFICER OR BOARD SECRETARY __________________________________________ ________________________________________________________________________________________________ ____________________________________________________________________________ ___________________________________________________ ___________


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