Fillable Ohio Public Employees Retirement System (University of Toledo)

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Ohio Public Employees Retirement System (University of Toledo)

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Section 2 - Current Employment Information
A (Revised 3/09)
Personal History Record
Please turn page to complete remainder of form
Section 1 - Personal Information
If this is an elected position or if you have been appointed to an elected position, provide date present elective service began.
Job Title
INSTRUCTIONS
1. As a public employee you are required to complete and file this Form within 30 days of commencing employment. Failure to do
so may limit the options available to you as well as delay transactions. Please fill out the form in blue or black ink.
2. For elected officials: An elected official, or person appointed to a publicly elected position, who is not retired from an Ohio
retirement system and does not have contributions on deposit with OPERS through previous elected service, has the option of
contributing to OPERS or Social Security. Elected officials who choose OPERS membership are required to contribute to OPERS
for all subsequent elected positions.
3. Be sure your date of birth and Social Security Number, which are used to identify your account, are entered correctly.
4. Sign the form in SECTION 4 - EMPLOYEE CERTIFICATION. DO NOT print or type.
5. The employer is required to complete SECTION 5 - EMPLOYER CERTIFICATION.
6. The employer is required to mail the completed form to OPERS at the above address immediately upon hire.
Are you legally married?
Social Security Number
Last Name
Date Of Birth
First Name MI
Male Female
Street or Mailing Address
City
State ZIP Code
Apt. Number
-
Gender
Work Phone Number
Home Phone Number
Cell Phone Number
E-mail Address
Yes No
Maiden Name
Postal Code
Province Country
Ohio Public Employees Retirement System
277 East Town Street, Columbus, Ohio 43215-4642
1-800-222-PERS (7377) www.opers.org
*A*
OH
Section 3 - Prior Service Information
Section 5 - Employer Certification
Section 4 - Employee Certification
If “yes,” list employer(s)
If “yes,” give first
date of public
1. Have you previously worked in public employment in Ohio?
Is this an elected position?
Is this a law enforcement position?
E
2. Do you have previous public service for which OPERS contributions were not submitted?
If “Yes” and you wish to request a determination relative to your non-contributing service, please provide OPERS with
a completed Certification of Unreported Public Service (Form AA).
I hereby certify that _______________________________________________ ___ began earning salary from which OPERS
retirement contributions are deducted with the above employer on the start date indicated above and the statements set
forth are true and accurate as disclosed by the records of
_____________________________________________________________________________________________________________
3. Are you currently a member of, have you been a member of, or are you receiving a disability benefit from any of the
following retirement systems?
(If applicable, check Refunded, Receiving a Disability Benefit or Receiving a Retirement Benefit.)
Yes
No
Receiving a
Retirement BenefitRefunded
Ohio Public Employees Retirement Systems (OPERS)
State Teachers Retirement Systems (STRS)
School Employees Retirement System (SERS)
Ohio Police and Fire Pension Fund (OP&F)
State Highway Patrol Retirement System (HPRS)
Cincinnati Retirement System (CRS)
___________________________________________________________________
Employee Signature (Do not print or type.)
Employee Name
Signature of Certifying Officer
I state that the information contained in this form is complete and true to the best of my knowledge and belief.
A (Revised 3/09)
Yes
No
Yes
No
Today's Date
Yes
No
Print Certifying Officer's Name
Ye
s
No
Receiv
ing a
Disability Benefit
Full-Time Part-Time
Elected Position Title
-
Employer Code
-
Employer Code
service:
Start Date
If "yes," provide Employer Code for elected position
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Ohio Public Employees Retirement System (University of Toledo)

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Completed 31 August 2020

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