Fillable Application for Membership

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Application for Membership

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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 Employer—Police/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
Name – First, Middle, Last
Mailing
Address
Street or P.O. Box
City
State
Zip Code
Date of Birth – mm/dd/yyyy
Position Title
Employment Start Date – mm/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
Date – mm/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 Employer—Police/Firefighter Certification in the Instructions.
Signature
Position Title
Date – mm/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.
Employer—Paper 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.
Employer—Electronic 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.
Employer—Police/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.
Employee—Benefits 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.
Employee—Eligibility 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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Application for Membership

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Completed 5 August 2020

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