INSTRUCTIONS: ARIZONA APPLICATION TO CALCULATE SEVERANCE FUND REPAYMENT (Form E1B)

Arizona elected officials enrolled in the state retirement fund who have contributed towards a severance fund can apply for a repayment using a form E1B if they regain employment with the state after being fired. This document can be obtained from the website maintained by the Elected Officials' Retirement Plan of the state of Arizona.

Arizona Application To Calculate Severance Fund Repayment E1B Step 1: On the first line of section 1, enter the member's name.

Arizona Application To Calculate Severance Fund Repayment E1B Step 2: On the second line of section 1, enter the member's Social Security number.

Arizona Application To Calculate Severance Fund Repayment E1B Step 3: On the third line of section 1, enter the member's street address, apartment number (if applicable), city, state and zip code.

Arizona Application To Calculate Severance Fund Repayment E1B Step 4: On the first line of section 2, enter the name of your current employer.

Arizona Application To Calculate Severance Fund Repayment E1B Step 5: On the second line of section 2, enter the current date of your membership.

Arizona Application To Calculate Severance Fund Repayment E1B Step 6: On the third line of section 2, enter the name of your previous employer.

Arizona Application To Calculate Severance Fund Repayment E1B Step 7: On the fourth line of section 2, enter the beginning service date of your previous employment.

Arizona Application To Calculate Severance Fund Repayment E1B Step 8: On the fifth line of section 2, enter the ending service date of your previous employment.

Arizona Application To Calculate Severance Fund Repayment E1B Step 9: On the first line of section 3, enter the amount refunded, if known.

Arizona Application To Calculate Severance Fund Repayment E1B Step 10: On the second line of section 3, enter the date of any such refund.

Arizona Application To Calculate Severance Fund Repayment E1B Step 11: On the first line of the last section, the date on which this form is being completed should be entered.

Arizona Application To Calculate Severance Fund Repayment E1B Step 12: On the second line of the last section, enter the member's signature.

Arizona Application To Calculate Severance Fund Repayment E1B Step 13: This form must be submitted within 90 days after re-employment is obtained. Repayment must be completed within a year to reinstate prior service credits.