PERS-7                     CLERKS’ AND REGISTERS’ SUPERNUMERARY  
 

 

 

 

 

           FUND 
             SPOUSAL BENEFITS 
 
                   Administrative Office of Courts 
                300 Dexter Avenue 
                   Montgomery, Alabama 36104-3741 
 

APPLICATION OF SURVIVING SPOUSE FOR 
CLERKS’ AND REGISTERS’ SPOUSAL BENEFITS 
 

 
638,  I hereby make application for supernumerary benefits as the surviving spouse. 

In accordance with the provisions of §12-17-142, Code of Alabama 1975, as amended by Act 95-

l.   Name of Deceased  Member:____________________________________________________    

                                                                                          (First)                              (Middle)                           (Last) 
              
              2.   Date of Death of Deceased Member:________________________________________ 
                                                                                    (Month)                 (Day)                  (Year) 

             3.   Position Held by Deceased Member:______________________________________________ 

 

4.   Name of Surviving Spouse: _____________________________________________________ 

                                                                       (First)                             (Middle)                             (Last) 
 
              5.   Date of  Birth of Surviving Spouse: _________________________________________ 
                                                                                        (Month)                  (Day)                    (Year) 

 

 

6.   Surviving Spouse’s Social Security Number:__________________________________ 

7.   Mailing Address and Telephone Number of Surviving Spouse: 

                   _______________________________________________ 

 
                    _______________________________________________ 

     

     _______________________________________________ Telephone No:_________________ 

8.   I understand that benefits are payable to me each month until my death or remarriage, and I  

                    agree to immediately notify the Administrative Office of Courts if I every remarry. 

9.   I hereby certify that I am the lawful surviving spouse of the deceased member named above  

                    and qualify for spousal benefits as indicated on the reverse side of this form. 

                   __________________________                     _______________________________________ 
                           (Date)                                                                         (Signature of Surviving Spouse) 

tate of Alabama, County of  _______________________ 

    On this ________day of_________________________, 20________, personally appeared before me, 

________________________________the surviving spouse of _______________________________,the 

ormer clerk/register of __________________________and made oath that the Statements made are true. 

 

   

   

 

   

   

   

   

   

   

   

   

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__________________________________________ 

Notary Public 
                      
My Commission Expires________________________ 
 

Back)        CLERKS’ AND REGISTERS’ SUPERNUMERARY FUND     (CONTINUED) 

               ______________________________________________________________________________________________________ 
                            
                                      If the clerk or register had not assumed supernumerary status at the time of his/her death, the following 
Information (Items 1-4) must be provided by the surviving spouse, unless eligibility is pursuant to #5 below. 
     1.   I certify that subsequent to October 1, 1976, my spouse made the appropriate monthly contributions 
           into the Clerks’ and Registers’ Supernumerary Fund and that he/she served as _________________ 
           for the following period or periods of time: 

          from  __________________________________ to _______________________________________ 

          from  __________________________________ to _______________________________________ 
           (Attached is a notarized declaration from the Chairman or clerk of the County Commission setting forth the dates  
              of service.) 

    2.   I certify that my spouse purchased prior service credit and/or made monthly contributions into the 
           Clerks’ and Registers’ Supernumerary Fund for a total of __________years and __________months. 

    3.   I certify that at the time of his/her death, my spouse was _________years of age. (Attached is a copy 
           of my spouse’s birth certificate or other such documentation which provides sufficient proof of the 
            date of his/her birth. 

    4.   (a)   I certify that at the time of his/her death my spouse was eligible for supernumerary status in 
                  accordance with §12-17-140, Code of Alabama 1975. (Check the appropriate statement 
                  of eligibility). 
                  (1)  Served as much as five (5) years as circuit clerk or register, and had become permanently, 
                         physically or mentally unable to carry out the duties of the office on a full-time basis 
                         immediately prior to his/her death. 
                   (2)  Served for twelve years as circuit clerk or register and had reached or passed 65 years 
                          of age. 
                   (3)      (a)  Served for 15 years as circuit clerk and was not less than 62 years of age at the time 
                                    of his/her death, or; 
                              (b)   Served as circuit clerk or register for more than 15 years and had attained the age of 
                                     62, less one year for each year of service in excess of fifteen, but was not less  than 
                                     70 years of age. 
                   (4)   Served continuously for 10 years as circuit clerk or register and was not less than 55 years 
                            of age. 
                   (5)   Served for not less than 18 years or 3 full terms and was not less that 55 years of age. 

                                               or 

    5.     I am eligible for spousal benefits pursuant to §12-17-142, as amended by Act 95-638, and certify 
             that my spouse was serving as circuit clerk on October 19,1990, at the time of his/her death had at 
              last 12 years of service, and I was appointed to serve the reminder of his/her unexpired term as 
              circuit court  clerk. 

               ______________________________________________________________________________________________________ 

ENDORSEMENT OF THE ADMINISTRATIVE DIRECTOR OF COURTS 
 

I,__________________________________________________, in my capacity as Administrative Director 
of courts for the State of Alabama, find that ________________________________________,served as  
clerk/register of the circuit court and that his/her spouse______________________________________ 
is  entitled to receive benefits from the Clerks’ and Registers’ Supernumerary Fund in the State Treasury 
pursuant to §12-1 7-142, Code of Alabama 1975, as amended by Act 95-638. 

one this the _____________________day of 

  D

                
 
____________________________,20_____________.               Administrative Director of Courts 
               ______________________________________________________________________________________________________ 

_______________________________ 

  

 Copy:      (1) Honorable______________________________(Chairman, Board of County Commission)  
                 (2) Applicant                              (3) Retirement Systems                 (4)AOC Payroll Clerk 

   

 

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