Fillable Fresno State University - CalPERS Reciprocal Self-Certification Form

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Fresno State University - CalPERS Reciprocal Self-Certification Form

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PERS-EAMD-801 (6/2018) Page 1 of 4
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
Reciprocal Self-Certification Form
Complete the following information and return this form to your personnel office within 10 business days. To ensure this form is completed
correctly, please reference the enclosed List of Qualifying Public Retirement Systems and instructions.
Section 1. Member Information
Member Name: (Last) (First) (Middle)
Date of Birth: CalPERS ID:
Membership Status in Qualifying Public Retirement Systems:
I have not been a member of a qualifying public retirement system in California. (skip to section 3)
I have membership in a defined benefit plan under a qualifying public retirement system in California other than CalPERS.
(complete section 2 with membership information for each qualifying public retirement system)
Section 2. Qualifying Reciprocal Membership Information
Name of Most Recent Public Retirement System:
Membership Date:
/ /
Separation Date*:
/ /
☐Retired* or ☐Refunded*
Date: / /
Name of Prior Public Retirement System:
Membership Date:
/ /
Separation Date*:
/ /
☐Retired* or ☐Refunded*
Date: / /
Name of Prior Public Retirement System:
Membership Date:
/ /
Separation Date*:
/ /
☐Retired* or ☐Refunded*
Date: / /
*Please provide dates, if applicable. Not all sections may be applicable for each Public Retirement System.
Section 3. Sign and Certify
I understand that by accepting employment in a qualified public retirement system, I am subject to the applicable laws and
regulations of that system. I also understand that completing this form is not a request to establish reciprocity.
I hereby certify that the foregoing information has been verified with the qualifying public retirement system as true and correct
and any information found to be incorrect may require corrections to my CalPERS account including, but not limited to, my
retirement enrollment level and adjustments to my member contributions. CalPERS may make any necessary corrections to my
account to ensure I am properly enrolled and eligible to receive the correct retirement benefits.
Member Signature: Date:
Section 4. To Be Completed by Employer Only
Name of CalPERS Agency:
CalPERS Business Partner ID: Member’s Enrollment Eligibility Date:
Designee of Employer: (print name) Designees’ Title:
Designee Signature: Date:
The employer must retain this form in the member’s file for auditing purposes.
For more direction regarding how to process the Reciprocal Self-Certification Form, please refer to our employer reference guides.
California State University, Fresno
6935813478
Juanita Aguilar Human Resources Manager - Benefits
Page 2 of 4
Name of Public Retirement System
Alameda County Employees’ Retirement Association^
City and County of San Francisco Employees’ Retirement System*
City of Concord Retirement System*
City of Costa Mesa Public Retirement System*
City of Fresno Retirement System
City of Pasadena Fire and Police Retirement System
City of San Clemente*
Contra Costa County Employees’ Retirement Association^
Contra Costa Water District
East Bay Municipal Utility District
East Bay Regional Park District
Fresno County Employees’ Retirement Association^
Imperial County Employees’ Retirement Association^
Judges Retirement System II
Kern County Employees’ Retirement System^
Legislators’ Retirement System
Los Angeles City Employees’ Retirement System
Los Angeles County Employees’ Retirement Association^
Los Angeles County Metropolitan Transportation Authority
Marin County Employees’ Retirement Association^
Mendocino County Employees’ Retirement Association^
Merced County Employees’ Retirement Association^
Oakland Municipal Employees’ Retirement System (City of
Oakland)
Orange County Employees’ Retirement System^
Sacramento City Employees’ Retirement System*
Sacramento County Employees’ Retirement System^
San Bernardino County Retirement Association^
San Diego City Employees’ Retirement System
San Diego County Employees’ Retirement Association^
San Joaquin County Employees’ Retirement Association^
San Jose Federated City Employees’ Retirement System
San Luis Obispo County Pension Trust
San Mateo County Employees’ Retirement Association^
Santa Barbara County Employees’ Retirement System^
Sonoma County Employees’ Retirement Association^
Stanislaus County Employees’ Retirement Association^
State Teachers’ Retirement System
Tulare County Employees’ Retirement Association^
University of California Retirement Program
Ventura County Employees’ Retirement Association^
*=Also CalPERS-covered agency ^=1937 Act Counties
Payroll Tech:______________ Date:________
Staff MPP Faculty Lecturer
TA GA ISA
List of Qualifying Public Retirement Systems in California
Phone: ___________
Emailed to SCO on: __________
Reciprocal packet: Y / NA
Plan
CalPERS State Misc & Cadet
8346 POFF Unit 8:
POFF MPP:
PERS-EAMD-801
(6/2018)
On or after 1/1/2013 PEPRA
2% @ 62 = 2N
2.5% @ 57= 3H
2.5% @ 57= 3Z
TM
CalPERS Rehired Annuitant
Other: NM
On or Before 01/14/11
2% @ 55 = 08
3% @ 50 = 52
3% @ 50 = 54
On or after 1/15/2011
2% @ 60 = 2Z
2.5% @ 55= 3P
2.5% @ 57= 3R
________________________(HR initials)
Submitted to Benefits Analyst: ____________
SSN: _____________
CalPERS Member? Refunded Y / N
If you would like help with this form, please complete SSN and Phone and Benefits office will contact you.
PERS-EAMD-801 (6/2018) Page 3 of 4
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
Dear Member,
The California Public Employees’ Retirement System (CalPERS) requires all members hired after
January 1, 2013 complete the Reciprocal Self-Certification Form (PERS-EAMD-801) to provide essential
information that will be used by your employer to enroll you in CalPERS membership.
This form obtains information regarding your membership in other qualifying public retirement systems
and must be returned to your employer within 10 business days of receipt. Use the instructions provided
on the back of the form and reference the List of Qualifying Public Retirement Systems for assistance.
Information regarding your membership in a defined benefit plan for any of the listed qualifying public
retirement system must be provided. However, information related to CalPERS membership should
not be included when completing this form, as this data is already stored in the CalPERS system.
It is your responsibility to ensure the accuracy and completeness of the information you provide.
Inaccurate information may result in adjustments to your account which could lead to adverse impacts
such as incurring financial obligations that you and your employer will be responsible to fulfill.
For more information regarding the Reciprocal Self-Certification Form, please visit our website at
www.calpers.ca.gov.
Please note: The completion of the Reciprocal Self-Certification Form does not establish reciprocity, nor
is it a request to establish reciprocity. To request that reciprocity be established, download the When
You Change Retirement Systems (PUB 16) publication to obtain the Confirmation of Intent to Establish
Reciprocity When Changing Retirement Systems (PERS-CASD-255) form. This publication is available at
www.calpers.ca.gov.
Sincerely,
Membership Services
Enclosures: List of Qualifying Public Retirement Systems in California, Reciprocal Self-Certification
Form, and Directions for Completing Reciprocal Self-Certification Form
PERS-EAMD-801 (6/2018) Page 4 of 4
Instructions for Completing the Reciprocal Self-Certification Form
Section 1.
Member
Information
• Complete the required fields with your name, date of birth, and CalPERS ID.
• Check one of the appropriate boxes to indicate if you have had membership in a defined
benefit plan in one of the qualifying public retirement systems named on the enclosed list.
- If you have not been a member of any of the qualifying public retirement systems,
mark the first box and skip to section 3.
- If you have membership in a defined benefit plan of any of the qualifying public
retirement systems on the enclosed list, mark the second box and continue to section
2.
- This form is to obtain information regarding your membership in other qualifying public
retirement systems; do not include CalPERS membership on this form.
Section 2.
Qualifying
Reciprocal
Membership
Information
• In the first column, titled “Name of Public Retirement System,” list the name of any qualifying
public retirement systems you are a member of a defined benefit plan.
- If you are a member of multiple qualifying public retirement systems, please provide
the name of each system beginning with the most recent in descending order.
- Please reference the enclosed List of Qualifying Public Retirement Systems in
California. Only systems named on this list should be provided on the Reciprocal Self-
Certification Form.
• In the second column, titled “Membership Date,” list your membership date in the qualifying
public retirement system.
- You must provide a full date, including month, date, and year, which corresponds to
each qualifying public retirement system listed.
- If you are unsure of your membership date, please contact the qualifying public
retirement system to confirm information prior to completing the form.
• In the third column, titled “Separation Date,” list your separation date from the qualifying
public retirement system.
- This section may not be applicable for all qualifying public retirement systems. If you
have not separated from the qualifying public retirement system, leave this field blank.
- If you have separated from the qualifying public retirement system, you must provide a
full date including month, date, and year.
- If you are unsure of your separation date, please contact the qualifying public
retirement system to confirm information prior to completing the form.
• In the fourth column, titled “Retired or Refunded,” indicate if you have retired or refunded
from the qualifying public retirement system.
- This section may not be applicable for all qualifying public retirement systems. If you
have not retired or refunded from the qualifying public retirement system, leave this
field blank.
- If you have retired or refunded from the qualifying public retirement system, mark the
appropriate box and provide a full date including month, date, and year.
- Retired: You have separated from the qualifying public retirement system and receive a
monthly retirement allowance.
- Refunded: You have terminated your membership in the qualifying public retirement
system by withdrawing your contributions.
Section 3.
Sign and
Certify
• Please read the statement. Then, sign your name and date the document before returning it to
your personnel office.
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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Fresno State University - CalPERS Reciprocal Self-Certification Form

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