RS102
Revised: 08/2016
Page 1 of 2
Public Employee Retirement System of Idaho
P. O. Box 83720, Boise, ID 83720-0078
1-800-451-8228 208-334-3365 Fax 208-334-3805
www.persi.idaho.gov frontdesk@persi.idaho.gov
*RS102*
Application for Membership
Purpose of the Form
Use this form to advise PERSI you are a new employee or a rehire who might be eligible for PERSI membership.
Instructions
Complete the form in blue or black ink.
Employee and employer
Read About Form RS102, attached.
Employer
Read the employer steps under the attached Instructions to determine if this form is necessary. If eligibility is
from Police/Firefighter certification, read EmployerPolice/Firefighter Certification in the Instructions.
Member Social Security Number Member PERSI ID Number*
* A PERSI ID is only required for members
with multiple PERSI accounts.
Member Information
NameFirst, Middle, Last
Mailing
Address
Street or P.O. Box
City
State
Zip Code
Date of Birthmm/dd/yyyy
Position Title
Employment Start Datemm/dd/yyyy
Marital Status
Single
Married
Contribution Information
I have contributed to PERSI before this
present employment.
Yes
No
Benefits Information
I am currently receiving a monthly benefit
payment from PERSI.
Yes
No
Gender
Male
Female
Employee Acknowledgment
As a condition of my employment under the requirements of Idaho Code, Title 59, Chapter 13, I declare that the
statements above are complete and correct to the best of my knowledge.
Signature
Datemm/dd/yyyy
Employer Certification
I certify that the above-named applicant is an employee as defined in Idaho Code §59-1302(14) and that the
information above is complete and correct to the best of my knowledge.
Employer Name
PERSI Employer Number
Employee Eligibility
General member
Teacher
Elected official
Police/Firefighter
Note: If eligibility is from Police/Firefighter certification, read EmployerPolice/Firefighter Certification in the Instructions.
Signature
Position Title
Datemm/dd/yyyy
RS102
Revised: 08/2016
Page 2 of 2
Public Employee Retirement System of Idaho
P. O. Box 83720, Boise, ID 83720-0078
1-800-451-8228 208-334-3365 Fax 208-334-3805
www.persi.idaho.gov frontdesk@persi.idaho.gov
About Form RS102
Instructions
Complete the form in blue or black ink.
Employee
1 Complete the Member Information and Employee Acknowledgement sections.
2 Attach a copy of your Social Security card.
3 Return the form to your employer.
4 Also complete a form RS115 Beneficiary Designation and send it to PERSI.
EmployerPaper Reporting
1 Complete the Employer Certification section to certify that the employee meets the definition of an employee
eligible for PERSI membership.
2 Include the information from the form in your Transmittal Report of Employee Deductions.
3 Send the form to PERSI.
4 Advise the employee to send a form RS115 Beneficiary Designation to PERSI.
5 If the employee is a retired PERSI member, complete form RS132 Certification of Employment of Retired Member,
have the employee complete the employee section, and send the form to PERSI.
EmployerElectronic Reporting
1 Do not use this form. Include the information in your Transmittal Report of Employee Deductions.
2 Advise the employee to send a form RS115 Beneficiary Designation to PERSI.
3 If the employee is a retired PERSI member, complete form RS132 Certification of Employment of Retired Member,
have the employee complete the employee section, and send the form to PERSI.
EmployerPolice/Firefighter Certification
If eligibility is from Police/Firefighter certification, complete form RS118 Employer Certification of Police Officer
Status or form RS118A Employer Certification of Firefighter Status and attach a copy.
EmployeeBenefits Information for Retired Members
In the Benefits Information field, check Yes if you are a PERSI retired member and currently receiving monthly
benefit payments from PERSI.
Working Retired Members
As a retired member, you can work and continue to receive benefit payments if you work less than 20 hours per
week or less than five consecutive months.
If you are retired member and returning to work for the same employer, your benefit payments might be affected,
as outlined in the explanation of form RS132 Certification of Employment of a Retired Member.
EmployeeEligibility for Public Employment
You may receive credit for prior public employment. The employers listed below may be eligible.
State of Idaho
Educational organizations of the State of Idaho (for example, school districts and universities)
Counties, cities, and other political subdivisions of the State of Idaho
Some U.S. military service
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