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CORRECTIONS OFFICER RETIREMENT PLAN 3010 E. Camelback Rd., Suite 200, Phoenix, Arizona 85016 (602) 255-5575 FAX (602) 296-2368 www.psprs.com FORM COSS Page 1 of 2 08/11 OUT OF STATE SERVICE AFFIDAVIT

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Arizona psprs COSS overpayments misrepresentations Camelback misrepresentation foregoing forfeiture refunded forfeited subsection pre Pursuant certify entitles subdivision credited calculation Notary Classification Expires audit revoked approximate CORP T

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