State of Alabama 
Unified Judicial System 

PERS-5                          Rev.  6/13      

DECLARATION OF INTENTION TO 
ASSUME SUPERNUMERARY STATUS 
(Clerk’s and Register’s Supernumerary)

Date:

                                                                  TO:             Director, Human Resources Division 
                                                                        Administrative Office of Courts  
                                                   300 Dexter Avenue 
                  
                                                                        Montgomery, Alabama 36104-3741 

FROM: Name: _________________________________          Supernumerary Mailing Address:

            Title: __________________________________      

            Circuit: ________________________________  

            County: ________________________________           Retirement Phone Number:(__)_____________

            Social Security Number: __________________         e-mail Address:__________________________

Spouse’s Name: _________________________

1.    I hereby elect to become a supernumerary   CIRCUIT        DISTRICT      Clerk, effective ______________
                                                                                      

(Check One)                                                    (Date)                 

2. 

I certify that I have made the appropriate monthly contributions into the Clerk's and Register's 

Supernumerary Fund and that I have served as  Circuit or District Clerk for the following period or 

periods of time:_______________________  to

                                        ;                                           to        

.  

3.     I certify that I have purchased prior service credit and/or made monthly contributions into the Clerk's and    

 Register's Supernumerary Fund for a total of                 years. 

   4.     I certify that I am            years of age. (Attached is a copy of my birth certificate and other such documentation,

           i.e. marriage certificate, change of name, which provides sufficient proof of the date of my birth.)    

5. 

I certify that I am eligible for supernumerary status in accordance with Section 12-17-140, Code of Alabama  

 (1975).  (Check the applicable statement of eligibility)  

Served as much as five (5) years as Circuit   District   Clerk, and have become permanently  
physically or mentally unable to carry out the duties of the office on a full-time basis and have  
attained the age fifty-five (55). (Attached are certificates signed by three (3) reputable physicians  
establishing proof of disability).

     Served for twelve (12) years as   Circuit   District   Clerk and have reached the age of sixty-five (65). 

     Served for fifteen (15) years as    Circuit   District   Clerk and have reached the age of sixty-two (62). 

     Served as    Circuit    District    Clerk for more than fifteen (15) years and have attained age sixty-two  

(62), less  one year for each year of service in excess of fifteen (15) (minimum age of 55). 

     Served as   Circuit   District Clerk eighteen (18) years, or 3 full terms and have attained age fifty-five 

(55).

     
    

 PERS-5 (Back)     Rev. 6/13

  6.    Yes     No   I certify that I have taken the oath of office for supernumerary clerks in accordance with Section 12-17-    

141, Code of Alabama (1975), and that once I have assumed supernumerary status, I shall accept 
appointment by the Chief Justice of the Supreme Court of Alabama to any vacancy in the office of 
Circuit Clerk in the county which I have previously served.  (Attached is my completed supernumerary 
Oath of Office) 

Sworn to and subscribed before me this the 

             day of                     , 20      .    

                                         

                                                        
            Notary                                                                                                                   Signature of Clerk                    

ENDORSEMENT OF THE ADMINISTRATIVE DIRECTOR OF COURTS 

I, 

                                                                                   , in my capacity as Administrative Director of Courts for the  

State of Alabama, find that                                                                                                                              clerk

of circuit court, is eligible to assume supernumerary status on                                                              ,pursuant to the

provisions of Section 12-17-140 et seq., Code of Alabama 1975. 

Done this the            day of 

                                 , 20                                                                           
                                                                                                                                 Administrative Director of Courts

Copy to:   

                                                    (1) AOC Human Resources                                   (2) Secretary of State   

                  (3) Comptroller 

                                                    (4) Hon.                                                                           Chairman, Board of County Commission) 

                                                    (5) Judge of Probate                         (6) Clerk/Register                                     (7) Presiding Circuit Judge