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POLICE RETIREMENT SYSTEM OF KANSAS CITY, MISSOURI

CIVILIAN EMPLOYEES’ RETIREMENT SYSTEM OF THE POLICE DEPARMENT OF KANSAS

CITY, MISSOURI

APPLICATION FOR CREDITABLE SERVICE DUE TO PERIOD OF

ACTIVE DUTY MILITARY SERVICE

Under the provisions of subsection 3 of section 86.1110 RSMo. (Police plan) or subsection 3 of section

86.1500 RSMo. (Civilian Employees’ plan), after August 28, 2015, a member who returns to service

from a leave of absence for military service shall be entitled to service credit for the time spent in such

military service only to the extent such member pays any required member contributions for such time,

unless granted a waiver by the Retirement Board.

A member who elects to make application for creditable service under this provision must make the

payment of any required member contributions within a time period equal to three times the period of

uniformed service, not to exceed five years, from the date of return to active service with the Police

Department. In all cases, payment must be completed prior to commencement of benefits to the

member from the Retirement System.

The undersigned member of the Police Retirement System of Kansas City, Missouri or Civilian

Employees’ Retirement System of the Police Department of Kansas City, Missouri hereby certifies that

the following information is correct and makes application for creditable service due to a specific

period of military service.

Name: ____________________________________________ Serial #: _____________

Dates of military service (use separate application for each period):

From: ______________________________ To: _______________________________

Documentation must be submitted with application. You must include a copy of your orders that

cover the dates of your unpaid leave, a verification of completion of military service under honorable

conditions, and Military Leave of Absence worksheet obtained from the Retirement System Office. In

order for your application to be considered by the Military Leave Review Committee, it must be

complete and include all required documentation or it will be returned to you.

Under the provisions of subsection 3 of section 86.1110 RSMo. or subsection 3 of section 86.1500

RSMo., the Retirement Board may waive the required contributions for a leave of absence due to active

duty military service, not to exceed three years of creditable service, when the member provides duty

orders under Title 10 or Title 32 U.S.C. and discharge from active duty documentation in the form of a

DD214 or NGB 23.

______ I request that the Retirement Board waive the required member contributions for the period of

active duty military service shown above. I have attached a copy of my orders and DD214 or NGB 23,

as required.

Signed _________________________________________ Date ___________________

Member’s signature

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Application For Creditable Service Due To Period Of Active Duty Military Service Form - Police Retirement System - Kansas City, Missouri