Fillable Request for Service Credit Cost Information Service Prior (City of Riverside, California)

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Request for Service Credit Cost Information Service Prior (City of Riverside, California)

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BROWSE CITY OF RIVERSIDE, CALIFORNIA (CA) FORMS

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Request for Service Credit Cost Information—
Service Prior to Membership
PERS-MSD-370 (9/18) Page 1 of 4
888 CalPERS (or 888-225-7377)
•
TTY: (877) 249-7442
Employer
Address
City State ZIP Code
Were you compensated for this employment?
c
No
c
Yes
Was the service rendered as an independent contractor or paid through a third party or temporary
employment agency?
c
No
c
Yes If yes, attach a copy of your independent contract with this form.
Employment From (mm/dd/yyyy) To (mm/dd/yyyy) Location
Employment From (mm/dd/yyyy) To (mm/dd/yyyy) Location
Employment From (mm/dd/yyyy) To (mm/dd/yyyy) Location
Did you work for another CalPERS-covered employer during the same employment period(s) indicated above?
c
No
c
Yes If yes, submit an additional request form for each CalPERS-covered employer.
Section 1
About You
Section 2
Prior Employment Information
List the name and
address of the employer
where the service was
earned. If this was a
certificated position,
contact the State Teachers’
Retirement System.
List the dates and
employment location
for which you are
requesting credit.
Obtain a cost estimate
from our Service Credit
Cost Estimator at
www.calpers.ca.gov/
servicecreditestimator.
Section 3
Member Certification
I hereby certify that the above information is true and correct. I understand it is my responsibility to ensure
this form is employer certified, when applicable, and received by CalPERS.
Signature Date (mm/dd/yyyy)
• If the service was performed for the State of California or a California State University, sign this form
and mail it to CalPERS, P.O. Box 4000, Sacramento, CA 95812-4000.
• If the service was performed for the University of California, a CalPERS-covered public agency, or a school,
forward this form to the appropriate employer for completion of pages 2–4 before returning to CalPERS.
Your valid election to
purchase service credit must
be received by CalPERS
at least one day prior to
your retirement date.
Name of Member (Last Name, First Name, Middle Initial) Social Security Number or CalPERS ID
Member Mailing Address
City State ZIP Code Daytime Phone
What date do you plan to retire?
Are you a member of a reciprocal agency?
c
No
c
Yes
If yes, what agency?
Retirement Date (mm/dd/yyyy)
( )
Put your name and Social
Security number or CalPERS ID
at the top of every page
Member Name Social Security Number or CalPERS ID
PERS-MSD-370 (9/18) Page 2 of 4
Section 4
Employer Certification
Section 5
Pay Period Detail
Complete the required
Pay Period Detail for the
requested time period.
After completing
Sections 4–5 and before
submitting these forms
to CalPERS, provide
copies of this form to:
• your payroll/fiscal
department,
• the employee, and
• your own agency’s
records.
If the service was
performed for the State of
California or California
State University, employer
certification is not required.
Reminder: If the employee has indicated a retirement date in Section 1, it is imperative that CalPERS receive this
completed Employer Certification section and Pay Period Detail in Section 5 promptly. Delays in receiving this information
from your agency could affect the employee’s ability to make their election prior to retirement.
Did the employee contribute to a retirement plan, other than CalPERS, during the specified time period?
c
No
c
Yes
Plan Type:
c
Defined Benefit
c
Defined Contribution
If the employee contributed to a Defined Benefit (DB) plan, attach DB plan information to this form.
Plan Name:
Was the service rendered as an independent contractor or paid through a third party or temporary
employment agency?
c
No
c
Yes
For teachers’ assistants in a credential program only:
Did the employee require a temporary certificate from a California teacher training institution to serve
as a teacher assistant during their SPM employment period?
c
No
c
Yes
If yes, attach a copy of the duty description/statement for the teacher assistant position, personnel forms,
or any records that support this employment.
Employer Name
Please complete all areas for the period this person was employed by your agency. You must provide service
period dates, position titles, pay rates, hours worked, and earnings for each pay period. Please indicate any
overtime, special compensation, and holiday pay in a separate row. Also, indicate if the employee was subject
to mandatory furloughs by pay period, or the frequency.
Government Code section 20221 specifies employers are required to furnish CalPERS with
information requested.
For help completing this form, visit www.calpers.ca.gov and to view the Circular Letters concerning
employer certification guidelines.
Appointment Tenure
c
Permanent
c
Indeterminate
c
Seasonal
c
Temporary
c
Other (Explain):
Term End Date (mm/dd/yyyy)
Term End Date (mm/dd/yyyy)
Put your name and Social
Security number or CalPERS ID
at the top of every page
Member Name Social Security Number or CalPERS ID
Mail to:
CalPERS Member Account Management Division • P.O. Box 4000, Sacramento, California 95812-4000
PERS-MSD-370 (9/18) Page 3 of 4
Section 5, continued
Pay Period Detail
Please keep this information attached to the Request for Service Credit Cost Information.
Start Date
(mm/dd/yyyy)
End Date
(mm/dd/yyyy) Position Title
Full-Time
Pay Rate
(Hourly/Daily/Monthly)
Time
Worked
(In Hours) Earnings
Time Base
(Full Time/
Part Time)
Months
per Year
(10, 11, 12)
Continue on back if necessary.
A fillable version of this form is available at www.calpers.ca.gov/docs/forms-publications/service-prior-membership.pdf.
Statement and Signature of Personnel or Payroll Officer
Required: By signing, I certify the following:
1. The information provided in Sections 4 and 5 is true, complete, and correct to the best of my knowledge and belief;
2. I am an authorized representative of the agency named in Section 5 and am qualified to certify this form;
3. I understand this form provides CalPERS with the information required to assess eligibility, calculate the cost, and determine
the amount of purchasable service credit that, if elected, will be included in the member’s retirement calculation;
4. I understand the agency named in Section 5 is accepting any employer liability associated with this service credit purchase.
Signature Title Date (mm/dd/yyyy)
Printed Name Business Phone Fax
Email
( ) ( )
Put your name and Social
Security number or CalPERS ID
at the top of every page
Member Name Social Security Number or CalPERS ID
Mail to:
CalPERS Member Account Management Division • P.O. Box 4000, Sacramento, California 95812-4000
Section 5, continued
Pay Period Detail
PERS-MSD-370 (9/18) Page 4 of 4
Start Date
(mm/dd/yyyy)
End Date
(mm/dd/yyyy) Position Title
Full-Time
Pay Rate
(Hourly/Daily/Monthly)
Time
Worked
(In Hours) Earnings
Time Base
(Full Time/
Part Time)
Months
per Year
(10, 11, 12)
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Request for Service Credit Cost Information Service Prior (City of Riverside, California)

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Completed 4 August 2020

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