Fillable Prior Exempt Service Questionnaire (California)

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Prior Exempt Service Questionnaire (California)

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(rev 08/2021)CalHR 004
Page 1 of 2
Prior Exempt Service Questionnaire
California Department of Human Resources
State of California
To: Date:
From: Personnel Office
Subject: Prior Exempt Service
Please complete and sign this form regarding possible prior exempt service. Prior exempt service
includes employment in the University of California System, the California State University System, the
California State Legislature, or a function of a Federal/local government that was blanketed (transferred)
into California State Government. It is important that you notate any prior service credit because it may
entitle you to additional benefits, including additional State service towards your vacation accrual rate. In
some instances, prior exempt service may also be used for seniority if allowed under the provisions of
your current bargaining unit contract.
This form and verification of prior exempt service should be returned to your Personnel Office as soon
as possible. Attach copies of any documentation that verifies the dates and time base (or number of
hours if intermittently employed) of your prior employment. Your Personnel Office will send your
verification data to the California Department of Human Resources (CalHR), where the amount of
service to be credited will be determined.
I have no prior exempt service.
I have prior exempt services as described below.
My prior exempt service has already been verified by CalHR
Verification is attached (See the back of this form for verification standards).
Verification is NOT attached (If not attached, please use the form CalHR-039).
Former Employer Title Exact Dates From/To
Time Base/Number
of Hours Per Month
Employee Signature Date
Phone Number
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(rev 08/2021)CalHR 004
Page 2 of 2
VERIFICATION STANDARDS
The California Department of Human Resources (CalHR) will determine whether the verification data
that is submitted will be added to your State service total. The documentation that you provide must be
written and verify the exact dates, and the time base (or number of hours if intermittently employed) of
your prior employment. Specific employment verification standards are listed below.
UNIVERSITY OF CALIFORNIA SERVICE
Submit written verification of your student or nonstudent status at the time of employment from the
University Registrar's Office. Also, provide copies of your "Record of Earnings" obtained from the
University's Payroll Office.
CALIFORNIA STATE UNIVERSITY SERVICE
For nonstudent service from June 1, 1961, through December 31, 1976, you must submit a copy of your
"Employee Record Card," which may be obtained from the Campus Personnel Office.
For nonstudent service before June 1, 1961, and after December 31, 1976, official data is available to
CalHR; therefore, no verification is required.
CALIFORNIA STATE LEGISLATURE
Contact the personnel office of the Legislative Branch (Assembly/Senate) where you were employed
and request a letter that verifies the exact dates and time base of your prior service.
FORMER FEDERAL OR LOCAL GOVERNMENT SERVICE
Please provide the department or agency name prior to the blanketing (transfer) and the date you
entered in to California State Government employment. CalHR should have your prior employment
records on file.
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Prior Exempt Service Questionnaire (California)

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Completed 10 August 2021

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