Fill - Free fillable FRS Certification Form (University of West Florida) PDF form

11/07/16 Page 1 of 1

Statement on the Collection and Use of Social Security Numbers

Human Resources

In accordance with the requirements of Florida law (Section 119.071, Florida Statutes), the University of West Florida

collects social security numbers only if specifically authorized or required by law or if imperative for the performance of

the University’s duties and responsibilities. The University may collect social security numbers for some or all of the

following purposes: identity tracking and management; billing and payments; credit worthiness; data collection;

reconciliation and tracking; benefit processing; tax and scholarship reporting; financial aid processing; student health

services, and reporting to authorized state and federal government agencies. Federal and state laws require us to protect

social security numbers from disclosure to unauthorized parties. Students and employees are assigned UWF

identification numbers to assist in tracking and protecting their personal information.

UWF Forms

Form Purpose

Purpose for SSN#

Statutory Authority

Mandated,

Authorized or

Business Imperative

FRS Certification Form

Eligibility to be employed

Applicant

Identification

Section 119.071(5)(a)6.g,

F.S.

Mandated

Level II Background

Screening Request Form

Eligibility to be employed in

a position of special trust

Applicant/employee

identification

Section 119.071(4)(a)2.b.,

F. S.

Mandated

Verification of Employment

Authorization Release

Employment verification

Employee

identification

Section

119.071(5)(a)(2)(a)(ll), F.S.

Business Imperative

Third Party Non-UWF

Forms

Purpose

Purpose of SSN#

Statutory Authority

Mandated,

Authorized or

Business Imperative

Form I-9, Employment

Eligibility Verification (US

Department of Homeland

Security)

Verify each new employee

(both citizen and noncitizen)

hired after Nov 6, 1986, is

authorized to work in the

United States.

Citizen and

noncitizen

identification

U.S. Dept. of Homeland

Security, U.S. Citizenship

and Immigration Services;

Immigration Reform and

Control Act of 1986, Pub. L.

99-603(8 USC 1324a)

Mandated

Form W-4, Employee’s

Withholding Allowance

Certificate

Tax reporting

For employee

identification

I.R.C. Section 6109

Mandated

Florida retirement

contribution reports and

forms (Florida Department of

Revenue)

Administration of pension

benefits

For employee

identification

Section 119.071(6)(g), F.S.

Business Imperative

Worker’s Compensation

Amerisys forms on behalf of

Risk Management, STARS

reports of lost wages and

First Report of Injury

For report and

documentation of work-

related injury and follow up

For employee

identification

Section 440.185(2)(b), F.S.

Mandated

I.R.C. Section 403b,457b

contribution reports (Internal

Revenue Service)

Employee enrollment and

claims

For employee

identification

I.R.C. Section 6109

Mandated

State of Florida New Hire

Report (Department of

Revenue)

Administration of various

programs: child support

enforcement, Medicaid,

unemployment

compensation, Food Stamp,

aid to disabled, etc.

New hire

identification

Section 409.2576, F.S.

Mandated

State sponsored insurance

enrollment forms and reports

(group health, life, and

dental coverage) (limited to

dependents)

Administration of health

benefits

Dependent

identification

Section 119.071(6)(f), F.S.

Business Imperative

Agency for Workforce

Innovation Unemployment

Compensation forms

Verification of benefits

eligibility

Employee

identification and

verification with

Social Security

Administration

Section 443.091(1)(g), F.S.

Mandated

FICA Alternative Plan Forms

(OPS Retirement)

Selection of 401(a)

Investment options

and Beneficiaries

Reporting

(OBRA 90) IRC

3121(b)(7)(F).

Business Imperative

CERT Revised 05/2018 EMPLOYERS: RETAIN THIS FORM IN THE EMPLOYEE’S PERSONNEL FILE. DO NOT SEND THIS FORM TO THE FRS, UNLESS REQUESTED.

This form is not an offer of employment or an enrollment form. If hired, a Retirement Choice kit may be mailed to your home with enrollment instructions.

Florida Retirement System (FRS) - Certification Form

Name

Social Security No.

Agency Name

Previous or Current FRS Employer

Complete Section I if you have never been a member of a State of Florida administered retirement plan.

Complete Section II if you are a current or previous member AND Section III if not retired OR Section IV if retired.

I. I have never been a member of a State of Florida administered retirement plan.

SIGNATURE DATE

II. I was or currently am a member of the following State of Florida administered retirement plan (also complete Section III or IV)

FRS Pension Plan (incl. DROP) FRS Investment Plan State University System Optional Retirement Program (SUSORP)

State Community College System Optional Retirement Program (SCCSORP)

Senior Management Service Optional Annuity Program (SMSOAP)

Other

III. I am not retired from any State of Florida administered retirement plan. I understand that if it is later

determined that I was a retiree and was reemployed during the first 6 calendar months after I retired or

after my DROP termination date, or at any time during the 7

through the 12

calendar months after I

retired or after my DROP termination date, I must repay all unauthorized benefits received (see Section

IV for details), or, if in the Investment Plan, terminate my employment. My employer may also be liable

for repaying any unauthorized benefits I received.

SIGNATURE DATE

Retiree Definition

You are considered

retired if:

1. You have re-

ceived any bene-

fits under the

FRS Pension

Plan, including

DROP (does not

include a with-

drawal of em-

ployee contribu-

tions), or

2. You have taken

any distribution

(including a roll-

over) from the

FRS Investment

Plan, or other

state adminis-

tered retirement

programs offered

by state universi-

ties (SUSORP),

state community

colleges

(SCCSORP),

state govern-

ment for senior

managers

(SMSOAP), or

local govern-

ments for senior

managers.

IV. I am retired from a State of Florida administered retirement plan. My FRS Pension Plan retirement ef-

fective date, DROP termination date, or date I received my first distribution from the FRS Investment

Plan, SUSORP, SCCSORP, SMSOAP, or other plan was ______________________.

Effective July 1, 2017, retirees of the Investment Plan, SUSORP, SCCSORP, and SMSOAP are

eligible for renewed membership in the Investment Plan, SUSORP, or SCCSORP.

I understand that as a Pension Plan retiree:

a. If I am employed by an FRS-participating employer in any type of position

during the first 6

calendar months after I retired or after my DROP termination date, my retirement and DROP

status are voided, all retirement and DROP benefits I received must be repaid,

and I must reapply

for retirement in order to receive future benefits.

b. If I am reemployed by an FRS-participating employer at any time during the 7

through the 12

cal-

endar months after I retired or after my DROP termination date, my monthly retirement benefit must

be suspended

and any unauthorized benefits received must be repaid.

My employer may also

be liable for repaying any unauthorized benefits I received.

I understand that as an Investment Plan, SUSORP, SCCSORP, or SMSOAP retiree:

a. If I am employed by an FRS-participating employer in any type of position

during the first 6

calendar months after I retired, I must repay

any benefits received or terminate employment for

an additional period to satisfy the 6 calendar month termination requirement.

b. If I am reemployed by an FRS-participating employer at any time during the 7

through the 12

cal-

endar months after my retirement, I will not be eligible for additional distributions until I terminate

employment or complete 12 calendar months of retirement.

SIGNATURE DATE

If you are not retired and earned FRS service after certain periods in 2002 (depending on your employer), you must rejoin the FRS retirement plan you were enrolled in when you

terminated FRS-participating employment. You may have a one-time 2

Election to switch FRS retirement plans. Also, alternative retirement programs are available to certain em-

ployees. Contact your employer for deadline and other information.

Positions include OPS, temporary, seasonal, substitute teachers, adjunct professors, part-time, full-time, regularly established, etc.

Florida law requires a return of all unauthorized Pension Plan benefit payments or Investment Plan distributions received by a member who has violated the FRS termination or

reemployment provisions. Similar provisions apply to unauthorized SUSORP, SCCSORP, or other state-administered plan distributions – contact that plan’s administrator for details.

There is one exception to the restrictions on reemployment limitations after retirement. If you are a retired law enforcement officer, you may only be reemployed as a school re-

source officer by an FRS-covered employer during the 7

through 12

calendar months after your retirement date or after your DROP termination date and receive both your salary

and retirement benefits.

STOP HERE

Fax To: 850-857-6030 – Attention: Retirement Section

University of West Florida, 11000 University Parkway, Human Resources, Pensacola, FL 32514

Fill Online, Printable, Fillable, Blank FRS Certification Form (University of West Florida) Form

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Fillable FRS Certification Form (University of West Florida)

Fill Online, Printable, Fillable, Blank FRS Certification Form (University of West Florida) Form

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