Fillable Reciprical-self-certification-calpers Reciprocal Self Certification Form

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Reciprical-self-certification-calpers Reciprocal Self Certification Form

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File type: PDF

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California Public Employees’ Retirement System
P.O. Box 942709 Sacramento, CA 94229-2709
888 CalPERS (or 888-225-7377)
TTY: (877) 249-7442
|
Fax: (916) 795-4166
www.calpers.ca.gov
PERS-EAMD-801 (8/17) Page 4 of 5
RECIPROCAL SELF-CERTIFICATION FORM
Complete the following information and return this form to your Personnel Office within 10 business days
Employee
Name
(Last) (First) (Middle)
Date of Birth
:
CalPERS ID
:
Check the applicable statement:
_____ I have not been a member of a qualifying Public Retirement System in California.
_____ I have prior membership under another Public Retirement System in California. (Complete the box below with
verified dates including month, date, and year. If you are unsure of the dates, please contact the Public Retirement
System to confirm information prior to completing form.)
*Please provide dates, if applicable. Not all sections may be applicable for each Reciprocal System.
I understand that by accepting employment in a qualified retirement system, I am subject to the applicable laws and
regulations of that system. I also understand that completing this form does not constitute a request to establish
reciprocity.
I hereby certify that the foregoing information has been verified as true and correct and any information found to be
incorrect may require corrections to my account in the California Public Employees’ Retirement System including, but
not limited to, my retirement enrollment level. CalPERS may make any necessary corrections to my account to ensure I
am properly enrolled and eligible to receive the correct retirement benefits.
_________________________ ________________ _____________ ____
Employee Signature Date
TO BE COMPLETED BY EMPLOYER ONLY:
The employer must retain this form in the employee’s file for auditing purposes.
Name of Most Recent Reciprocal System:
Membership Date:
/
/
Separation Date*:
/ /
☐
Retired*
☐
Refunded*
Date
: / /
Name of Prior Reciprocal System:
Membership Date:
/
/
Separation Date*:
/
/
☐
Retired*
☐
Refunded*
Date
: / /
Name of Prior Reciprocal System:
Membership Date:
/
/
Separation Date*:
/
/
☐
Retired*
☐
Refunded*
Date
: / /
Name of CalPERS Agency: CalPERS Business Partner ID: Employee’s CalPERS Original Hire Date:
Designee of Employer: (Print Name) (Title) Employee’s CalPERS Membership Eligibility Date:
Designee’s Signature: (Date)
2397715413
Diana Enos HR Manager
Privacy Notice
The privacy of personal information is of the utmost importance to CalPERS.
The following information is provided to you in compliance with the Information
Practices Act of 1977 and the Federal Privacy Act of 1974.
Information Purpose
The information requested is collected pursuant
to the Government Code (sections 20000 et seq.)
and will be used for administration of Board
duties under the Retirement Law, the Social
Security Act, and the Public Employees’ Medical
and Hospital Care Act, as the case may be.
Submission of the requested information is
mandatory. Failure to comply may result in
CalPERS being unable to perform its functions
regarding your status.
Please do not include information that is
not requested.
Social Security Numbers
Social Security numbers are collected on a
mandatory and voluntary basis. If this is CalPERS’
first request for disclosure of your Social Security
number, then disclosure is mandatory. If your
Social Security number has already been provided,
disclosure is voluntary. Due to the use of Social
Security numbers by other agencies for
identification purposes, we may be unable to
verify eligibility for benefits without the number.
Social Security numbers are used for the
following purposes:
1. Enrollee identification
2. Payroll deduction/state contributions
3. Billing of contracting agencies for employee/
employer contributions
4. Reports to CalPERS and other state agencies
5. Coordination of benefits among carriers
6. Resolving member appeals, complaints,
or grievances with health plan carriers
Information Disclosure
Portions of this information may be transferred
to other state agencies (such as your employer),
physicians, and insurance carriers, but only
in strict accordance with current statutes
regarding confidentiality.
Your Rights
You have the right to review your membership
files maintained by the System. For questions
about this notice, our Privacy Policy, or your rights,
please write to the CalPERS Privacy Ocer at
400 Q Street, Sacramento, CA 95811 or call us
at 888 CalPERS (or 888-225-7377).
May 2016
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Reciprical-self-certification-calpers Reciprocal Self Certification Form

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Completed 18 February 2020

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