INSTRUCTIONS: ARIZONA APPLICATION FOR A SEPARATION BENEFIT/DEFERRED BENEFIT (Form E6)

Arizona elected public officials who terminate their employment may either apply for a refund of money contributed to their state-administered retirement plan or apply to have benefits deferred until they are of age to collect. These requests are made using a form E6. This document can be obtained from the website of the Elected Officials' Retirement Plan of the State of Arizona.

Arizona Application For A Separation Benefit/Deferred Benefit E6 Step 1: Enter your name on the first line.

Arizona Application For A Separation Benefit/Deferred Benefit E6 Step 2: Enter your Social Security number on the second line.

Arizona Application For A Separation Benefit/Deferred Benefit E6 Step 3: Enter your street address, as well as your apartment number (if applicable) on the third line.

Arizona Application For A Separation Benefit/Deferred Benefit E6 Step 4: Enter your city, state and zip code on the fourth line.

Arizona Application For A Separation Benefit/Deferred Benefit E6 Step 5: Enter your phone number on the fifth line.

Arizona Application For A Separation Benefit/Deferred Benefit E6 Step 6: Enter your birth date on the sixth line.

Arizona Application For A Separation Benefit/Deferred Benefit E6 Step 7: Enter the name of your office on the seventh line.

Arizona Application For A Separation Benefit/Deferred Benefit E6 Step 8: Enter the beginning date of your employment in this office on the eighth line.

Arizona Application For A Separation Benefit/Deferred Benefit E6 Step 9: Enter the termination date of your employment in this office on the ninth line.

Arizona Application For A Separation Benefit/Deferred Benefit E6 Step 10: If you place your initials on the blank line in the section labeled "Refund Option," you are requesting a refund of contributions to the elected officials' retirement plan.

Arizona Application For A Separation Benefit/Deferred Benefit E6 Step 11: If you place your initials on the blank line in the section labeled "Deferred Pension Office," you are leaving your credits on deposit in anticipation of collection when eligible.

Arizona Application For A Separation Benefit/Deferred Benefit E6 Step 12: You must initial the next blank line.

Arizona Application For A Separation Benefit/Deferred Benefit E6 Step 13: Sign and date the bottom of the first page. Have your governing authority complete the certification of termination on the second page.