Fillable New-hire-calpers-reciprocity-form Member Reciprocal Self-Certification Form

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New-hire-calpers-reciprocity-form Member Reciprocal Self-Certification Form

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California Public Employees’ Retirement System
Customer Account Services Division
Retirement Account Services Section
P.O. Box 942709
Sacramento, CA 94229-2709
TTY: (877) 249-7442
888 CalPERS (or 888-225-7377) phone • (916) 795-4166 fax
www.calpers.ca.gov
PERS-CASD-801 (12/12)
MEMBER 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: ______________________________________
NAME OF MOST RECENT RECIPROCAL RETIREMENT SYSTEM: _______________________________
PERMANENT SEPARATION DATE FROM MOST RECENT RECIPROCAL RETIREMENT SYSTEM: _____
_______________________________________________________________________________________
FIRST MEMBERSHIP DATE IN ANY PRIOR CALIFORNIA PUBLIC RETIREMENT SYSTEM THAT IS
SUBJECT TO RECIPROCITY: ______________________________________________________________
(Check the applicable statement)
_____ I have not been a member of another California Public Retirement System within the last six months.
_____ I was a member and am retired from the _______________________________ Retirement System and
subsequently became employed by a CalPERS-covered employer.
_____ I was a member of the _____________________________ Retirement System and became employed by
a CalPERS-covered employer within six months after separating from employment with the previous
reciprocal retirement system.
I understand that by accepting employment in a specific retirement system, I am subject to the applicable laws and
regulations of that system. I also understand that completing this form does not constitute a request to establish
reciprocity. I must complete and return the “Election to Coordinate Retirement When Changing Retirement
Systems,” (PERS-MSD-255) Form 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.
______________________________________________ ______________________________
SIGNATURE OF EMPLOYEE DATE
TO BE COMPLETED BY EMPLOYER ONLY:
NAME OF CalPERS AGENCY: CalPERS BUSINESS PARTNER ID:
______________________________________________ _______________________________________
CalPERS MEMBERSHIP ELIGIBILITY DATE ORIGINAL HIRE DATE WITH YOUR AGENCY:
WITH YOUR AGENCY:
______________________________________________ _______________________________________
DATE MEMBER RECIPROCAL SELF-CERTIFICATION FORM GIVEN TO EMPLOYEE: ________________
DATE MEMBER RECIPROCAL SELF-CERTIFICATION FORM RECEIVED FROM EMPLOYEE: __________
______________________________________ _________________ _____________
(Please Print) DESIGNEE OF EMPLOYER TITLE DATE
________________________________________________________________________________________
DESIGNEE’S SIGNATURE
CSU Channel Islands
2397715413
Diana Enos
HR Manager
PERS-CASD-801 (12/12)
MEMBER RECIPROCAL SELF-CERTIFICATION FORM
Instructions
Reciprocity is an agreement among public retirement systems to allow members to separate from one
public employer and enter into employment with another public employer within a specific time limit
without losing some valuable retirement and related benefit rights.
The Public Employees’ Pension Reform Act of 2013 (PEPRA), effective January 1, 2013, requires a
CalPERS covered employer to determine the applicable PEPRA retirement benefit formula for new
employees. CalPERS refers to all members that do not fit within the PEPRA definition of a “new
member
1
” as “classic members” who are subject to the Public Employees’ Retirement Law (PERL).
PEPRA allows a member after January 1, 2013, to retain his/her classic member retirement benefit
status if the member continues his/her membership in all previous California Public Retirement
System(s) by leaving his/her service credit and contributions (if any) on deposit, and the member
enters into employment that results in CalPERS membership within six months of separating from the
most recent California Public Retirement System. Classic member status also requires the
membership date to be on or before December 31, 2012, in a California Public Retirement System in
which reciprocity is established.
EMPLOYER INSTRUCTIONS
1. Employers must provide the Member Reciprocal Self-Certification Form to all new employees
upon eligibility for membership.
2. Employers must sign and date the Member Reciprocal Self-Certification Form on the date the form
is given to the employee.
3. Upon receipt of the completed Member Reciprocal Self-Certification Form, the employer will enter
the date the employee returns the form.
4. The employer will enroll the new employee into CalPERS membership through my|CalPERS
based on the information provided on the Member Reciprocal Self-Certification Form.
my|CalPERS will determine the proper retirement benefit formula. If an employer believes the
retirement benefit formula is incorrect, employers may contact CalPERS at 1-888-225-7377.
5. It is the responsibility of the employer to retain the completed Member Reciprocal Self-Certification
Form in the employee’s employment records for auditing purposes.
1
A new member is defined in 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.
PERS-CASD-801 (12/12)
EMPLOYEE INSTRUCTIONS
1. The Member Reciprocal Self-Certification Form will assist your employer in determining whether
you are considered a new member or a classic member under PEPRA.
2. As the new employee, you must complete, sign and date the Member Reciprocal Self-Certification
Form to self-certify your most recent service in a reciprocal California Public Retirement System,
your first membership date in any previous California Public Retirement System and your
permanent separation date from the most recent California Public Retirement System; or indicate
that you are not a member of any California Public Retirement System that is subject to
Reciprocity.
3. As the new employee, you must return the Member Reciprocal Self-Certification Form to your
Personnel Office within 10 business days of employment.
4. The completion of the Member 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 web-site at: www.calpers.ca.gov
and download the publication: “When You
Change Retirement Systems”, PUB-16. It is the responsibility of the employee to complete
and send the “Election to Coordinate Retirement When Changing Retirement Systems,”
PERS-MSD-255 Form to CalPERS.
Reciprocal 1937 Act Counties Reciprocal Public Agencies
Alameda Sacramento *City of Concord
Contra Costa San Bernardino *City of Costa Mesa (Safety employees only)
Fresno San Diego City of Fresno (Miscellaneous and
Imperial San Joaquin Safety Retirement Systems)
Kern San Mateo City of Los Angeles (non-Safety only)
Los Angeles Santa Barbara City of Oakland (non-Safety
Marin Sonoma employees only)
Mendocino Stanislaus City of Pasadena (Fire and Police
Merced Tulare Retirement System)
Orange Ventura *City of Sacramento
*City of San Clemente (non-Safety
employees only)
Non-Reciprocal & UCRS Retirement Systems City of San Diego
*City and County of San Francisco
Non-reciprocal systems are not covered by City of San Jose
reciprocity retirement laws, but participate Contra Costa Water District
in retirement agreements with other systems. County of San Luis Obispo
East Bay Municipal Utility District
State Teachers’ Retirement System East Bay Regional Park District
Legislators’ Retirement System (Safety employees only)
Judges’ Retirement System Los Angeles County Metropolitan
Judges’ Retirement System II Transportation Authority
University of California Retirement System (Non-Contract Employees’ Retirement
Income Plan, formerly Southern
California Rapid Transit District)
*Also CalPERS-covered agency
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New-hire-calpers-reciprocity-form Member Reciprocal Self-Certification Form

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Completed 16 February 2020

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