Service Purchase Application Form
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4Form 160
Service purchase application form
PA R T A : O M E R S E M P L O Y E R O R P U B L I C
S E C T O R E M P L O Y E R / P E N S I O N P L A N
Use this form to apply for a cost to purchase service with your current
To purchase service with more than one employer, complete
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OMERS employer, a former OMERS employer, or OMERS-associated
a separate Form 160 for each time period.
employer, or a former public sector employer/pension plan. If you buy
For service with a private sector employer, use the Form 260 – Service
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back this service, it becomes credited service in the OMERS Primary Plan.
purchase application form, Private sector employer/pension plan.
How to use the Form 160
Tip! For a quick cost estimate, try the Buy-back Estimator in
We recommend you first complete the Proof of previous earnings and
myOMERS. It draws information from your OMERS file. To register, go
service (see below). This goes to the former employer to complete and
to , click on myOMERS, and follow the steps. (You’ll
may take several weeks to be returned.
need your OMERS membership number.)
For OMERS service that was previously refunded, please see Section 1.
Personal information is collected for pension administration purposes
by OMERS under the authority of Section 35 of the OMERS ct, 2006.
Service purchase application form (Part A)
OMERS does not share your personal information with any other
Complete the member information in Section 1 and sign in Section 3.
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person other than for purposes of pension plan administration, and, by
Ask your current OMERS employer to complete Sections 2 and 3.
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providing personal information, you consent to its use for those
This confirms the annual salary rate used for your service purchase
purposes. The collection, use, retention and destruction of personal
cost, as at the date of your request.
information are subject to our Privacy Policy at .
Tip! Keep your personal information private: do not send Part A to your
Any questions regarding the collection of personal information should
former employer.
be directed to OMERS Client Services at 1-800-387-0813.
roof of previous earnings and service (Part B)
** If your former employer is unable to complete this form, you may
Complete and sign Section 1 – Member Information.
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complete a Form 169 – Statutory declaration for proof of eligible [OMERS]
Send Part B to your OMERS employer or former employer/pension plan
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service or Form 269 – Statutory declaration for proof of service [non-
to complete.
OMERS] available at .
The employer is to return the completed and signed form to you.*
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** Proof-of-age document
Once you have the completed forms from your current and former
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employers, submit them to OMERS (mail or fax; no email) along
A legible photocopy (not the original) of any one of these with
your date of birth:
with proof of your age.** Please write your OMERS membership
number on all documents.
Birth certificate
Canadian driver’s licence
OMERS will calculate the cost of the service and prepare an election
Canadian passport
Canadian citizenship papers
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form with your purchase options, and send it to you by mail.
Baptismal papers
Canadian registration of birth
Adoption papers
Certificate of Indian Status
Section 1 is to be completed by the member
1. MEMBER INFORMATION (please complete all fields in this section)
Group number
OMERS membership number
Birthdate (m/d/y)
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Last name
First name
Middle name
Mr.
Mrs.
Ms.
Other:
Address (street number and name)
City
Province
Postal code
ON
Daytime telephone
Email
Name of current employer
(
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Previously refunded OMERS service
(For privacy, you may complete this section after your current employer returns this form to you.)
Is this request for previously refunded service in the OMERS Plan?
Yes
No
If yes, OMERS may have this information on file. You need only submit Part A.
If yes, when did the service occur?
Former employer’s name
Any other information that may have changed in your OMERS record (e.g., married name)?
Section 2 is to be completed by the current employer
2. SERVICE COST INFORMATION
Current annual salary rate
For a member who is other-than-continuous full-time (OTCFT) or works for a school board, the salary should be
$
annualized. Examples:
A member earns $27 per hour (paid vacation included). A 12-month, full-time employee in the same job class
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works 2080 hours per year (40-hour week). The annualized salary rate is $56,160 ($27 x 2080 hours).
A 10-month school board employee (working full-time hours) has a salary rate of $35,000. The annualized salary
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rate is $42,000 ($35,000 ÷ 10 x 12).
Employee class (for optional service only)
Type of service purchase:
Buy-back
Optional service
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