State of Alabama Unified 
Judicial System 

Form CR-2A Rev.11/13/2018 

CLERKS’ AND REGISTERS’ SUPERNUMERARY FUND 
EMPLOYEES’ RETIREMENT SYSTEM OF ALABAMA 
300 Dexter Avenue, Montgomery, AL  36104 

NOTICE OF FINAL DEPOSIT AND  
REQUEST FOR REFUND 

 For Retirement Systems Office Use Only 

 Date 

   Amount 

The applicant should fill out Part 1 and forward to the Administrative Office of Courts, 300 Dexter Avenue, 
Montgomery, AL 36104-3741 

Part 1 

   Social Security              

   ERS Acct. No. 

PLEASE PRINT No Initials 
Name: ____________________________________________________________ Date of Birth: ________________________ 
    Last                     First Given                      Middle Given                            Maiden                                                    Month           Day            Year 

Mail refund to __________________________________________________________________________________________ 

  (Street Address or Box Number)                                                   (City)                                             (State)                            (Zip Code) 

Any change to the address given here must be submitted to the Retirement Systems of Alabama in writing and be signed by the applicant. 
Note: Refund will NOT be mailed until the Retirement System receives the member’s final deposit and this Form CR-2A 

 

AFFIDAVIT THAT EMPLOYMENT HAS PERMANENTLY TERMINATED 

NOTARY PUBLIC                                                                                                ______________________________________ 

      (Date) 

I hereby certify that I have permanently terminated my employment as a Clerk or Register and request that the contributions and 
applicable interest be returned to me. I understand that receipt by me of applicable refund will release the Retirement System 
from any claim for other benefits. I understand that I am not entitled to the total interest credited to my account, but a portion of 
the total interest as determined by the number of years I have contributed.  

STATE OF ALABAMA, COUNTY OF ______________________ 

   ______________________________________ 

   (Signature of Member) 

Before me, the undersigned authority, a Notary Public in and for said County and State, on this day personally appeared the 
applicant for refund, known to me to be the person whose name is subscribed to the foregoing instrument, and declared to me 
upon oath that the forgoing instrument is true and correct. Given, under my hand and seal of office this ______ day of 
__________, ________. 

(If you have a seal, affix it) 
_______________________________________________________________________________________________________________________________ 
Part 2 

CERTIFICATION OF ADMINISTRATION OFFICE OF COURTS 

______________________________________ 
(Date) 

Last contribution to Supernumerary Fund to be included in the _________ report from the State Finance Department 

     (pay period) 

Date above-named ceased to be an employee _________________________________________________________________ 

    (Month)                                      (Day)                        (Year) 

Total period above-named has contributed to the Clerks’ and Registers’ Supernumerary Fund: 
_______________ years _____________ months 

I hereby certify the final salary payment has been made to the above-named and that this person has no further contract, written 
or oral, to return to employment of said agency. 

______________________________________________ 

  (Signature)   

  _____________________________________________ 
  (Official Title)