Name * First Last
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Home Phone - (###) - ### ####
Work Phone - (###) - ### ####
Mobile Phone - (###) - ### ####
Email
Are you currently employed by the school system? * Yes No
Are you retired from the school system? Yes No
What is your current occupation? *
What WV county do you live in? *
What WV county do you work in? *
If not currently a WV resident, please provide your personal work history as a public school employee and member of the Teacher’s Retirement System, including county where you lived and county where you worked.
During the time period 1990 through 1995, did you transfer from the Defined Benefit Plan to the Defined Contribution Plan or were you a new employee required to be in the Defined Contribution Plan? Transferred New Employee
What was the name of the representative who met with you with regard to transferring your retirement to VALIC under the Defined Contribution Plan?
Where did the presentation take place?
Approximately when did the presentation take place?
Please provide details of your experience with VALIC.
What amount has the Consolidated Public Retirement Board indicated you need to pay (if the issue passes) to become 100% vested at:
Vested at 65%
Vested at 75%
Would you like to be contacted by the Webb Law Firm about participating in the lawsuit against VALIC for misrepresentation and fraud? * Yes No
Type the letters you see in the image below.

What amount has the Consolidated Public Retirement Board indicated you need to pay (if the issue passes) to become 100% vested at: