Fillable PERS Member Reciprocal Self Certification 082017 Reciprocal Self Certification Form

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PERS Member Reciprocal Self Certification 082017 Reciprocal Self Certification Form

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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
PERS-CASD-801 (8/17) Page 1 of 5
Dear Member,
You are being provided with the background, explanation, and instructions for the Reciprocal
Self-Certification Form (PERS-CASD 801). Reciprocity among qualified Public Retirement Systems is to
allow members to separate from one qualified Public Retirement System and enter into employment
under another within a specific time period without losing valuable retirement and related benefit
rights.
With the implementation of the Public Employees’ Pension Reform Act of 2013 (PEPRA), Government
Code section 7522, on January 1, 2013, the California Public Employees’ Retirement System (CalPERS)
requires that employers provide you with this package to complete the Reciprocal Self-Certification
form. The Reciprocal Self-Certification form allows you to provide essential information to your
employer and will be used by your employer to enroll you into CalPERS membership and every new
appointment under CalPERS. This information will assist CalPERS in identifying the correct retirement
benefit level to enroll you into CalPERS. For more information regarding PEPRA, please see our website
at www.calpers.ca.gov.
Within 10 business days of membership or new appointment you must complete, sign, date, and submit
to your employer the Reciprocal Self-Certification form. When completing the form, reference the
attached list of qualifying Public Retirement Systems in California. Complete the form by indicating that
you are not a current or past member of a qualifying Public Retirement System; OR indicate that you
have prior membership in a qualifying Public Retirement System and complete the box listing your
previous membership dates, permanent separation dates, and retirement or refund dates, if applicable.
It is important to ensure you are providing accurate information so your retirement enrollment level can
be properly determined. It is your responsibility to ensure the accuracy of the data provided on the
Reciprocal Self-Certification Form. Inaccurate information may cause your account to reflect an incorrect
retirement enrollment level which can have many impacts to your account including ineligible
retirement benefit formulas, adverse effects on how your retirement benefit is calculated, and delays in
CalPERS processing timeframes. Providing inaccurate information may lead to future retroactive
adjustments to your member and employer contributions, and you and your employer will be
responsible for any debts that may occur.
Information to remember when completing the form:
Please ensure you are providing complete and accurate dates. You must provide a month, date,
and year. If you are unsure of the dates, please contact the qualifying Public Retirement System
to verify prior to completing the form.
For each prior Reciprocal System reported, you must provide the name of the qualifying Public
Retirement System and membership date. If you have separated, retired, or refunded from that
Reciprocal System, please indicate that by providing dates in the appropriate sections. If you
have not separated, retired, or refunded from that Reciprocal System, you may leave these
sections blank or indicate that by entering N/A (not applicable).
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
PERS-CASD-801 (8/17) Page 2 of 5
It is not necessary to include data related to employment covered by CalPERS when completing
this form as this information is already withheld in the CalPERS system.
Only include information related to a Defined Benefit Plan of a qualifying Public Retirement
System. Defined contribution plans are not eligible for reciprocity.
The completion of this form provides data to be used to enroll you into the correct retirement
enrollment formula. The completion of the Reciprocal Self-Certification Form does not establish
reciprocity, nor is it a request to establish reciprocity. In order to request that reciprocity be
established, visit the CalPERS website, www.calpers.ca.gov and download the publication When You
Change Retirement Systems. It is the responsibility of the employee to complete and send the form,
Confirmation of Intent to Establish Reciprocity When Changing Retirement Systems, to CalPERS.
Sincerely,
Membership Services
Enclosures: List of Qualifying Public Retirement Systems in California
Reciprocal Self-Certification Form (PERS-CASD-801)
List of Qualifying Public Retirement Systems in California
PERS-CASD-801 (8/17) Page 3 of 5
Name of County/Agency/System:
Qualification(s):
Alameda County^
City and County of San Francisco*
City of Concord*
City of Costa Mesa*
Safety Employees only
City of Fresno
Miscellaneous and Safety Retirement systems
City of Los Angeles
Non-Safety only
City of Oakland
Non-Safety only
City of Pasadena
Fire and Police Only
City of Sacramento*
City of San Clemente*
Non-Safety only
City of San Diego
City of San Jose
Contra Costa County^
Contra Costa Water District
County of San Luis Obispo
East Bay Municipal Utility District
East Bay Regional Park District
Safety Employees only
Fresno County^
Imperial County^
Judges’ Retirement System
Kern County^
Legislators’ Retirement System
Los Angeles County Metropolitan
Transportation Authority
Non-Contract Employees’ Retirement Income Plan, formerly
Southern California Rapid Transit District
Los Angeles County^
Marin County^
Mendocino County^
Merced County^
Orange County^
Sacramento County^
San Bernardino County^
San Diego County^
San Joaquin County^
San Mateo County^
Santa Barbara County^
Sonoma County^
Stanislaus County^
State Teachers’ Retirement System
Tulare County^
University of California Retirement System
Ventura County^
*=Also CalPERS-covered agency ^=1937 Act Counties
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
PERS-CASD-801 (8/17) Page 4 of 5
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)
Date of Birth
:
CalPERS ID
:
Check the applicable statement:
_____ I have not been a member of a qualifying Public Retirement System in California.
_____ I have prior membership under another Public Retirement System in California. (Complete the box below with
verified dates including month, date, and year. If you are unsure of the dates, please contact the Public Retirement
System to confirm information prior to completing form.)
*Please provide dates, if applicable. Not all sections may be applicable for each Reciprocal System.
I understand that by accepting employment in a qualified 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 hereby certify that the foregoing information has been verified as 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 retirement enrollment level. CalPERS may make any necessary corrections to my account to ensure I
am properly enrolled and eligible to receive the correct retirement benefits.
_________________________ ________________ _____________ ____
Employee Signature Date
TO BE COMPLETED BY EMPLOYER ONLY:
The employer must retain this form in the employee’s file for auditing purposes.
Membership Date:
/
/
Separation Date*:
/ /
☐
Retired*
☐
Refunded*
Date
: / /
Membership Date:
/
/
Separation Date*:
/
/
☐
Retired*
☐
Refunded*
Date
: / /
Membership Date:
/
/
Separation Date*:
/
/
☐
Retired*
☐
Refunded*
Date
: / /
Name of CalPERS Agency: CalPERS Business Partner ID: Employee’s CalPERS Original Hire Date:
Designee of Employer: (Print Name) (Title) Employee’s CalPERS Membership Eligibility Date:
Designee’s Signature: (Date)
PERS-CASD-801 (8/17) Page 5 of 5
RECIPROCAL SELF-CERTIFICATION FORM INSTRUCTIONS (EMPLOYER)
1. Employers must provide the Reciprocal Self-Certification Form to all employees upon membership.
2. Employers must sign and date the Reciprocal Self-Certification Form once received back from
employee.
3. The employer must enroll the employee into my|CalPERS utilizing the information provided on the
Reciprocal Self-Certification Form. If the employee indicates they are a prior member of a qualifying
Public Retirement System in California, be sure to complete the data fields in the Reciprocity panel
in my|CalPERS. Please enter the permanent separation date, retirement date, or refund date, if
applicable, as provided by the member. No CalPERS data should be entered on the reciprocity panel
as all CalPERS data is already stored in my|CalPERS.
4. The proper retirement benefit formula will be automatically determined by my|CalPERS. If you
believe the retirement benefit formula is incorrect, you may contact CalPERS at (888) 225-7377.
5. It is the responsibility of the employer to retain the completed Reciprocal Self-Certification Form in
the employee’s employment records for auditing purposes. Do not send a copy of the form to
CalPERS.
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PERS Member Reciprocal Self Certification 082017 Reciprocal Self Certification Form

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Completed 5 November 2019

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