Public Employees’ Retirement System of Mississippi
429 Mississippi Street, Jackson, MS 39201-1005 800.444.7377 601.359.3589 601.359.5261, fax
Reemployment of PERS Service Retiree Certification/Acknowledgement
Form 4BRevised 11/17/2017
Please print or type in black ink. A Form 4B, Reemployment of PERS Service Retiree Certification/Acknowledgement, should be submitted each
fiscal year (July 1 June 30) of reemployment. See Regulation 34, Reemployment after Retirement, for rules governing reemployment.
Completed form should be mailed or faxed to PERS. See bottom of form for contact information.
Retiree Information
First Name: _____________________________________ MI: _________ Last Name: ______________________________________________________
Mailing Address: ________________________________________________ City: ___________________________ State: _______ Zip: _____________
Social Security No.: _______________________________E-Mail: _______________________________________________________________________
Phone: ________________________________ Cellular Home Work Phone: _______________________________ Cellular Home Work
Position/Agency from which Retired: _______________________________________________ Retirement Date mm/dd/ccyy: ______________________
Annual Retiree Acknowledgement and Election Please check one.
I hereby acknowledge that I have read, understand, and agree to comply with the provisions for reemployment as outlined in PERS Board Regulation 34,
Reemployment after Retirement, which stipulates that I must be retired at least 90 days or I forfeit my retirement benefit. With that understanding, I make the
following annual election in accordance with Miss. Code Ann. § 25-11-127 (1972, as amended):
A. ____ I hereby elect to be employed by a covered employer for a period of time not to exceed one-half of the normal working days or hours for the full-time
equivalent position during the state fiscal year indicated in Section 3, and I will receive no more than one-half of the salary in effect for the position at
the time of employment. The normal working days or hours for the fulltime equivalent position are ______ days or ______ hours and I will work no
more than _______ days or ______ hours during the state fiscal year indicated in Section 3. The full-time annual salary authorized for this position is
$____________________ and I will earn no more than $____________________ during the state fiscal year indicated in Section 3.
B. ____ I hereby elect to earn an annual salary that will not exceed 25 percent of the final average compensation used in calculating my service retirement
allowance. My final average compensation at retirement was $____________________ and I will earn no more than $_____________________
from all PERS-covered employers during the state fiscal year indicated below.
Retiree’s Signature: _______________________________________________________________________ Date mm/dd/ccyy:______________________
Employer Certification This section should be completed by an authorized employer representative, not the retiree.
I hereby certify that the above-named individual, who is a service retiree receiving benefits from PERS, is employed in the below-named position in
accordance with the reemployment provisions as authorized in Miss Code Ann. § 25-11-127 (1972 as amended) and in accordance with the provisions of
PERS Regulation 34, Reemployment after Retirement. I understand that wages earned and paid to the above-named individual during this period of
employment will be reported in accordance with reporting requirements prescribed by PERS and the applicable employer contributions on the wages
actually paid must be submitted. I further understand that any person who makes a false statement or shall falsify or permit to be falsified any record of a
retirement plan administered by PERS in an attempt to defraud the plan may be subject to criminal prosecution, and with that understanding, I certify that the
below information is true and correct.
Retiree’s Position /Job Title: _________________________________________________ Fiscal Year of Reemployment (July 1 - June 30): ________
Retiree’s Hire Date mm/dd/ccyy: ___________________________________Termination Date mm/dd/ccyy: ____________________________________
Retiree Employed through Third Party: No Yes Name of Third Party: _____________________________________________________________
Employer Name: ____________________________________________________________ Employer No.: __________________ - _________________
Employer Representative’s Name: ________________________________ Employer Representative’s Title: _____________________________________
Employer Representative’s Phone: _________________________ Fax: _________________________ E-Mail: __________________________________
Employer Representative’s Signature: _________________________________________________________ Date mm/dd/ccyy: _____________________
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