State of Alabama 
Unified Judicial System 
Judicial Retirement Fund 

 Form PERS-3               Rev.  3/2019    

RE:  

 (Name) 

DECLARATION OF INTENTION TO RETIRE 
UNDER JUDICIAL RETIREMENT ACT OF THE 
STATE OF ALABAMA 
(Code of Alabama, 1975, Sections 12-18-1 through 12-18-91) 

Retirement Creates        
Vacancy      
  Yes  or       No

STATE OF ALABAMA                                                                                                                                             COUNTY 

 (Judicial Position) 

 (Place #) 

Before me the undersigned authority in and for said county in said state, personally appeared 

      who, being known to me and who being by me first duly sworn, deposes and says as follows: 

1.    I hereby elect to be retired on        service         disability     effective on  

       under the Alabama Judicial Retirement Act. (This will be the day following last work day) 

 month

day

year 

2.

I hereby certify that I have served continuously as a
(Present Judicial Position) of the State of Alabama since

3. Prior Service Credit (Complete if applicable)

      month

     day

         year 

a     I hereby certify that the Supreme Court of Alabama has judicially determined that I am entitled to count as credit  toward

retirement prior service totaling     

 years        months   

  days. A copy of that determination is attached hereto. 

   b     I further certify that the Judicial Retirement Fund of Alabama has determined that I am entitled to additional or other service   

credit totaling        years        months        days.  A copy of that determination or notice is attached hereto.  

I hereby certify that I am    years of age, having been born on the         day of      

  19     . A copy of my birth   

certificate or other official certification of age is attached hereto. 

I hereby certify that at the time my retirement becomes effective I shall take the oath of office as a retired judge and file the said

oath with the appropriate officials of the State of Alabama. 

(a)   My Social Security Number is  (last 4 digits) XXX-XX-
(b) My Spouse’s Name is
(c) My retirement mailing address is

Street  or Post Office  Box 

(d) My retirement telephone number is 
(e)
(f)    I desire that deductions for Federal Income Tax be withheld from my monthly retirement

I desire to continue State Hospital Insurance coverage

   State                                            Zip 
      email  
 No;      Dependant coverage       Yes  
      No 

 Yes  

 Yes  

City          

 No 

 If yes to either (e) or (f), I agree to execute and deliver to the Judicial Retirement Fund of Alabama a properly executed “IRS    
Form W4-P” and/or insurance Premium Deduction Authorization. I understand that execution and delivery of such forms are 
conditions precedent to having deductions withheld for either Federal Income Tax or State Insurance. 

SWORN TO and subscribed before me this the  
Day of                           , 20         . 

 Notary Public 

TO:   Judicial Retirement Fund 

 Retirement Systems of Alabama          
 201 South Union Street 
  Montgomery, AL 36104 

Declarant  

ENDORSEMENT OF CHIEF JUSTICE 

      ,  in my capacity as Chief Justice of the Supreme Court of Alabama find that 

   (Name of Retiree)    

 (Present Judicial Position) 

is eligible for

service

disability   retirement, to become effective on  

that he/she has attained sufficient years of service and age to comply with the provisions of Code of Alabama 1975, §§ 12-18-1 through 12-18-91 

   month      

day

year 

Done this the                day of 

     , 20     

Chief Justice 

opy To:    1.   Governor, State of Alabama 
2. Secretary of State
4.  Presiding Circuit Judge
3. Comptroller, State of Alabama      5.   Director, Administrative Office of Courts      7.   Chairman,

6.  Clerk,

       Judicial Circuit 
   County Commission 

4.

5.

6.

I,

  C