Form Crn-1 - Contribution Retention Notice - Delaware Office Of Pensions
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FORM: CRN-1
(Revised 3/2012)
STATE OF DELAWARE
OFFICE OF PENSIONS
CONTRIBUTIONS RETENTION NOTICE
I, ____________________________ EMPLID#____________________, have terminated my employment
(Employee Name)
with ________________________________________________________ effective ___________________.
(Name of Organization)
(Termination Date)
I hereby elect to leave my accumulated pension contributions in the Delaware Public Employees’ Retirement System
(DPERS) and continue to earn interest at a rate established by the Board of Pension Trustees. I have less than the required
years of service in a pension covered position to collect a future pension. I understand that if I have more than the required
years of service in a pension covered position, I must file a vested pension application through my organization’s Human
Resources Office.
Also, by leaving the contributions in DPERS, I retain my status as a member of the Retirement Plan should I later
return to service in a pension covered position and subsequently accumulate sufficient years to restore my prior service
credits.
I understand that by leaving my contributions in the Retirement Fund, I must notify the Office of Pensions of any
address or name changes during the period this election is in effect.
Signature:___________________________________
Telephone #: ____________________
Address:____________________________________
____________________________________
____________________________________
_________________________________________________________________________________________
THE FOLLOWING TO BE COMPLETED BY ORGANIZATION
I hereby certify that the above applicant has terminated employment with this organization effective ______________
(Termination Date)
and that this employee does not have the required years of service in a pension covered position to receive a future pension.
_______________________________________________
___________________________________
Authorized Signature
Title
_______________________________________________
__________________________
Name of Organization
Date
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