ennsylvania MEMBERSHIP ELECTION OR DECLINATION Byeernsyva _ 1, WHE alipetblc _ employee ot Ste Seow hereby acknowledge and certify that I have been netifed and understand the following. = Lam eligible to become a member of the Pennsylvania State Employees’ Retirement ‘system (SERS). = Members of SERS cantribute to SERS through automatic payroll deductions and, after vesting and retiring, are entitied to receive lifetime retirement benefits based on years of service, class of service, compensation, and other factors. ‘= {FT elect to become a member of SERS, I will remain a member of SERS for the duration of my current employment; and { may be required to remain a member of SERS through future employment with any SERS-participating employer, © IF do not elect to become a member of SERS within 30 days of the effective date of my current emplayment, or if T decline to become a member of SERS, I will not have another ‘apportunity to elect to become a member of SERS ar ta accrue SERS retirement credit during my current employment. ‘= Thave been directed to SERS’ website for additional Information and for SERS Retirement Counseling Center contact information. E-Trrareby elect to become a member of SERS. CC] Thereby decline to become a mamber of SERS. terre inn siaratur ee AENCY LIAISON CERTIFICATION {In accordance with Section $906(e) ofthe State Employees’ Retirement Code, 71 Pa. C.S. §5906(e), 4 forint ti Ceansbere— ‘have notified the above-ramed employee of the irevocabltty of electing or declining SERS membership anf/have directed the employee to SERS’ website for addtional information, including ‘SERS Retirement Counseling Center contact information and will submit this form to SERS upon completion. ete sees. whl acta