Public Employees’ Retirement System of Mississippi
429 Mississippi Street, Jackson, MS 39201-1005 800.444.7377 p 601.359.3589 p 601.359.1027 f www.pers.ms.gov
Employer Request for Member Information
Revised 07/01/2016
Please print or type in black ink. Refer to PERS Board Regulation 57, Release of Member Information to Participating Employers, for the
governing rules. Complete sections 1 through 4, and return form to the PERS executive director. See bottom of form for contact information.
Employer Representative
First Name: ________________________________________________ MI: ______ Last Name: _____________________________________________
Title: _____________________________________________________ Employer Name: ___________________________________________________
Employer Mailing Address: _________________________________________________ City: _____________________ State: _______ Zip: __________
Work Phone: ___________________________________________________ E-Mail: _______________________________________________________
Information Requested – Select one.
1. List of names and addresses on file for current or former employees
2. List of employees eligible to retire now or within ______ years based on service credit or age and service
3. List of employees retired from the agency
4. Demographic information on current or retired employees necessary for employer to provide health insurance coverage
5. Other: ________________________________________________________________________________________________________________
Purpose of Request
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
Employer Certification – This section must be signed by the Employer Representative and Employer Head, if different from the Employer
Representative.
We certify on behalf of the above-listed employer making this request that all information provided by PERS will be used solely for the purpose stated in the
request. Further, we certify that such information will remain confidential and will not be disclosed or released to any other party.
Employer Representative Signature: __________________________________________________ Date mm/dd/ccyy: ______________________________
Employer Head Name: ______________________________________________________ Title: _____________________________________________
Employer Head Signature: _________________________________________________________ Date mm/dd/ccyy: ______________________________
PERS Use Only
Request Decision
Date Received by PERS mm/dd/ccyy: __________________ Date Answered mm/dd/ccyy: ________________ Tracking No.: _______________________
Subject Matter: ________________________________________________________________________________________________________________
Approved Request Assigned to: ___________________________________________________________ Title: _____________________________
Denied Basis for Denial: ____________________________________________________________________
Attach copy of Notice of Denial.
Processing Individual’s Signature: ________________________________________________________ Date mm/dd/ccyy: ________________________
