AUTHORIZATION OF PAYROLL DEDUCTION FOR 
NON-CREDITED SERVICE TIME 
Please check one or more of the following that apply and complete the information: 
I hereby authorize GERS to start payroll deduction for payment of my non-credited service time effective from 
________ – ________ – ___________   for the amount of $ ____________________________________________ 
mm              dd                 yyyy 
(Enter the bi-weekly deduction amount - not less than minimum amount)
to pay off my prior service balance of $ ______________________. 
(Enter total contributions due)
I hereby authorize GERS to change payroll deduction for payment of my non-credited service time effective from
_______ – _______ – _______  from $ __________________________  to $_______________________________
mm            dd            yyyy
(Enter the previous bi-weekly
(Enter the bi-weekly deduction amount -  
deduction amount)
not less than minimum amount)
to pay off my prior service balance of $ __________________________. 
(Enter total contributions due)
I hereby enclose the following payment(s) for my non-credited service time to pay off my prior service balance of 
$ _____________________________ 
(Enter total contributions due)
Certified Check / Money Order No.
Amount 
____________________________________________
_____________________________
____________________________________________
_____________________________
____________________________________________
_____________________________
____________________________________________
_____________________________
____________________________________________
_____________________________
____________________________________________
_____________________________
Name in Full: __________________________________________
Signature: ____________________________________________
Social Security No: ___________ – ________ – _____________
Department: __________________________________________
Employee No.: _________________________________________
GERS-BEN111  REV 06
Internal Use Only 
Date Received: _____________
Date Submitted: ____________
GOVERNMENT EMPLOYEES RETIREMENT SYSTEM
3438 Kronprindsens Gade, GERS Complex - STE 1, St. Thomas, VI 00802-5750 • (340) 776-7703 • Fax (340) 776-4499
3005 Orange Grove, Lot #5, Christiansted, St. Croix, VI 00820-4313 • (340) 773-5480 • Fax (340) 773-5497