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ALAMO COMMUNITY COLLEGE DISTRICT (ACCD)
OPTIONAL RETIREMENT PROGRAM (ORP) VERIFICATION OF PREVIOUS COVERAGE

Name: ______________________________________ ___________________ _________________
SS Num. Banner ID

please print legibly
Address: __________________________________ ______________________ _____ ___________
Street Address or Box Number City State Zip Code

_____ Yes. I, the employee whose name and signature appear on this form, confirm that
I have previously participated in the Optional Retirement Program (ORP).

Or,

_____ No. I, the employee whose name and signature appear on this form, confirm that I have never
participated in the Optional Retirement Program (ORP). I understand that if it is discovered
that I did participate in an ORP account that ACCD will retroactively collect the monies that
should have been contributed, this amount may be taken in four or less pay periods.

Employee Signature: _________________________________________ Date: ____________________

Receipt of this form, signed and completed, is acknowledged by:

HR Benefits Representative: _______________________________________ Date: _______________

please print legibly

Instructions: Complete/ sign this form, submit original along with the required paperwork to your HR Benefits Representative.

orp election form 01042019
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