Fillable Calpers-reciprocity-rertification-2017 Member Reciprocal Self-Certification Form

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Calpers-reciprocity-rertification-2017 Member Reciprocal Self-Certification Form

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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
Employer Account Management Division
PERS-CASD-801 (6/16) Page 1 of 4
Dear Member,
Y
ou are being provided with the background, explanation, and instructions for the Reciprocal
Self-Certification Form (PERS-CASD 801).
W
ith the implementation of The Public Employees’ Pension Reform Act of 2013 (PEPRA) on
January 1, 2013, CalPERS requires that employers determine the applicable retirement benefit formula
for new employees. The Reciprocal Self-Certification form allows you to provide essential information
to your employer and will be used by your employer to enroll you into CalPERS membership. This
information will assist in identifying your retirement benefit level
1
.
R
eciprocity among public retirement systems is to allow members to separate from one public employer
and enter into employment with another public employer within a specific time limit without losing
valuable retirement and related benefit rights.
W
ithin 10 business days of employment you must complete, sign, date, and submit to your employer
the Reciprocal Self-Certification form. When completing the form, reference the attached list of
qualifying Public Retirement Systems in California. If applicable, list your previous membership date(s) in
the qualifying Public Retirement System and your permanent separation date(s); OR indicate that you
are not a current or past member of a qualifying Public Retirement System.
The completion of the Reciprocal Self-Certification Form does not establish reciprocity and is not a
request to establish reciprocity. In order to request that reciprocity be established, visit the CalPERS
website, www.calpers.ca.gov and download the publication When You Change Retirement Systems. It
is the responsibility of the employee
to complete and send the form, Confirmation of Intent to Establish
Reciprocity When Changing Retirement Systems to CalPERS.
S
incerely,
Membership Management Section
Enclosures: List of Qualifying Public Retirement Systems in California, Reciprocal Self-Certification form
1
A new member is defined in the Public Employees’ Retirement Law (PERL) under Government Code section 7522, the Public
Employees’ Pension Reform Act of 2013 (PEPRA), as any of the following:
•A new hire who is brought into CalPERS membership for the first time on or after January 1, 2013, who has no prior
membership in any California Public Retirement System.
•A new hire who is brought into CalPERS membership for the first time on or after January 1, 2013, who has a break in service
of greater than six months with another California Public Retirement System that is subject to Reciprocity.
•A member who first established CalPERS membership prior to January 1, 2013, who is rehired by a different CalPERS employer
after a break in service of greater than six months.
List of Qualifying Public Retirement Systems in California
PERS-CASD-801 (6/16) Page 2 of 4
Name of County/Agency/System:
Qualification(s):
Alameda County^
City and County of San Francisco*
City of Concord*
City of Costa Mesa*
Safety Employees only
City of Fresno
Miscellaneous and Safety Retirement systems
City of Los Angeles
Non-Safety only
City of Oakland
Non-Safety only
City of Pasadena
Fire and Police Only
City of Sacramento*
City of San Clemente*
Non-Safety only
City of San Diego
City of San Jose
Contra Costa County^
Contra Costa Water District
County of San Luis Obispo
East Bay Municipal Utility District
East Bay Regional Park District
Safety Employees only
Fresno County^
Imperial County^
Judges’ Retirement System
Kern County^
Legislators’ Retirement System
Los Angeles County Metropolitan
Transportation Authority
Non-Contract Employees’ Retirement Income Plan, formerly
Southern California Rapid Transit District
Los Angeles County^
Marin County^
Mendocino County^
Merced County^
Orange County^
Sacramento County^
San Bernardino County^
San Diego County^
San Joaquin County^
San Mateo County^
Santa Barbara County^
Sonoma County^
Stanislaus County^
State Teachers’ Retirement System
Tulare County^
University of California Retirement System
Ventura County^
*=Also CalPERS-covered agency ^=1937 Act Counties
California Public Employees’ Retirement System
P.O. Box 942709 Sac
ramento, CA 94229-2709
888 CalPERS (or 888-225-7377)
TTY: (877) 249-7442
|
Fax: (916) 795-4166
www.calpers.ca.gov
PERS-CASD-801 (6/16) Page 3 of 4
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)
Social Security Number or CalPERS ID Number:
Check the applicable statement:
_____ I have not been a member of CalPERS or of a qualifying Public Retirement System in California.
_____ I was a member of CalPERS or a qualifying Public Retirement System in California and terminated my
membership by withdrawing my funds.
_____ I am retired from CalPERS.
_____ I am retired from another Public Retirement System in California.
_____ I am an active member of CalPERS. I have funds on deposit with CalPERS.
_____ I am an active member of another Public Retirement System in California. (Complete the box below).
I understand that by accepting employment in a specific retirement system, I am subject to the applicable laws and regulat
ions
of that system. I also understand that completing this form does not constitute a request to establish reciprocity. I must
complete and return the form Confirmation of Intent to Establish Reciprocity When Changing Retirement Systems to CalPERS.
I hereby certify that the foregoing information is 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 date of
membership. 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:
Separation Date:
Name of Prior Reciprocal System:
Separation Date:
Name of Prior Reciprocal System:
Separation Date:
Name of CalPERS Agency:
CalPERS Business Partner ID:
Employees’ CalPERS Original Hire Date:
Designee of Employer:
(Print Name) (Title)
Employees’ CalPERS Membership Eligibility
Date:
Designee’s Signature:
(Date)
CSU Channel Islands
2397715413
Dia
na 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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Calpers-reciprocity-rertification-2017 Member Reciprocal Self-Certification Form

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Completed 18 February 2020

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