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8/8/2016 Election for Exclusion from the Coordinated Plan by a City Manager Public Employees Retirement Association 60 Empire Drive, Ste #200, Saint Paul, MN 55103-2088 PERA Employer Fax Number: 651 296-2493; Employer Phone Lines: 651 296-3636 or 1-888-892-PERA Information and Instructions: A city manager who had previously been enrolled in and contributed to the PERA Coordinated Plan has the option within six months of the commencement of the employment to be excluded from participating in the Coordinated Plan if the city council approves the membership revocation. Part A is to be completed by the City Manager/Administrator and returned to the employing city for completion and submission to PERA. The election for exclusion must be approved by the city council through a resolution. Contributions for credit under the Coordinated Plan will stop beginning with the paid date following the date on which PERA will receive this form unless the city manager requests a later discontinuous date. If a later effective date is requested, it must fall within the first six months of employment for the city manager. (The city representative should retain a copy of this form once completed.) PART A - FOR COMPLETION BY CITY MANAGER Name of City Manager Last First M.I. Soc. Sec. No -- Name of Employing City I revoke my membership in the Coordinated Plan as a city manager and request PERA coverage as follows: I choose to participate in the Defined Contribution Plan (DCP) on a prospective basis. I understand that this election is revocable and I may subsequently choose to discontinue the DCP membership. I chose to not have any PERA membership at this time. Note: Unless you request a later effective date (that is within your first six months of employment), the city will stop withholding Coordinated Plan deductions from your earnings effective with the paid date following the date on which PERA will receive this form. Regardless of the choice you make above, you are eligible to receive a refund of the Coordinated Plan employee deductions that had been made from your salary before the date on which PERA receives this form. To receive a refund of member deductions, you must file a refund application with PERA. As required by law, I state that I will not at any time seek authorization to purchase service credit under the Coordinated Plan for any period of the excluded service. I further understand that I have a one-time option to revoke this decision and, with city council approval, to reinstate my Coordinated Plan membership on a prospective basis but that I must do so in writing under the procedures established by the retirement system. Signature of City Manager/Administrator Date PART B - FOR COMPLETION BY EMPLOYER I state that the named individual is a city manager as defined in M.S. §353.028, subdivision. 1: …”city manager” means (1) a person duly appointed to and holding the position of city manager in a Plan B statutory city or in a home rule city operating under the “council-manager” form of government, or (2) a person appointed to and holding the position of chief administrative officer of a home rule charter city or a statutory city pursuant to a charter provision, ordinance or resolution establishing such a position and prescribing its duties and responsibilities… Date Coordinated Plan Exclusion is to be Effective Employer PERA ID No. Signature of City Representative Title Date Data collected on this form will be used by PERA staff for identification and administrative purposes. The person’s Social Security Number is classified as PRIVATE and will not be shared with an unauthorized person without written consent.