Bill Harrison

• Licensed [Job Title] - [Timeframe]N
• Licensed - (N.C . Teaching license

] Training - [Timeframe]

• If your employing unit is a Public School Unit, special provisions under Session Law 2023-48 may allow you to certify certain information that would cause the invoice and liability for an additional contribution calculated under G.S. 135-4(jj) and assessed under G.S. 135-8(f)(2) to be partially or fully canceled. If these provisions apply, please complete and return this form. It is your employing unit's responsibility to complete and return this form, if applicable, without guidance or reminders from the Retirement Systems Division. Your employing unit is required to pay 100% of the additional contribution unless this form is fully completed and received by RSD within 12 months from the date you were assessed of the additional contribution.
• This certification pertains to the additional contribution required for the following retirement under the Teachers’ and State Employees’ Retirement System (“TSERS”).
• Name of Retiring TSERS Member
• ORBIT Member Identification Number
• Name of Public School Unit
• ORBIT Agency Number

• I hereby certify (check one of the following):
• [ ] The Employer is not required to pay the additional contribution because the retirement meets the criteria of both G.S. 135-8(f)(2)f1.1.
• [ ] The Employer is required to pay 50% of the additional contribution because the retirement meets the criteria of both G.S. 135-8(f)(2)f1.1. and G.S. 135-8(f)(2)f2.1.
• I, the undersigned employer representative of the Public School Unit submitting this certification, certify that the information provided above is true and correct to the best of my knowledge and that I have the authority to submit this certification on my employer’s behalf. I also certify that I understand that G.S. 135-10 describes penalties for “knowingly mak[ing] any false statement” or “falsify[ing] or permit[ting] to be falsified any record or records of TSERS in an attempt to defraud TSERS.”
• Signature of Employer Representative __________________________ Date __________________________
• Employer Representative Name (Print) __________________________
• Position Title __________________________
• Telephone Number __________________________
• Note: This form must be returned by email to Orbit Employer Reporting (OER@nctreasurer.com).

• N.C. Department of State Treasurer, Retirement Systems Division
• 3200 Atlantic Avenue, Raleigh, North Carolina 27604
• NC.Retirement@nctreasurer.com
• (919) 814-4590