Form Es 0350 – Fill Out and Use This PDF

An employee who performs creditable service (Education Code Section 22119.5), and who is excluded from mandatory membership pursuant to Section 22601.5, 22602, or 22604, may elect membership in the California State Teachers’ Retirement System (CalSTRS) Defined Benefit Program at any time while employed to perform creditable service. If you elect membership below, then your election becomes irrevocable until you terminate employment. This form containing your election must be on file with CalSTRS before your employer submits contributions into the program.

EMPLOYEE CERTIFICATION

NAME (LAST, FIRST, INITIAL)			CLIENT ID OR SOCIAL SECURITY NUMBER
MAILING ADDRESS				POSITION TITLE
			(	)
CITY	STATE	ZIP CODE	HOME TELEPHONE

E-MAIL ADDRESS

With my signature below, I certify that I have received information from my employer on my eligibility to elect membership in CalSTRS Defined Benefit Program and that I am making the following election. I fully understand this election is irrevocable and applies to all future creditable service until I terminate employment.

I understand it is a crime to fail to disclose a material fact or to make any knowingly false material statements for the purpose of altering a benefit administered by CalSTRS and it may result in penalties, including restitution, up to one year in jail and a fine of up to $5,000 (Education Code Section 22010).

I elect membership 	I decline membership at this time 
SIGNATURE	DATE

TO BE COMPLETED BY EMPLOYER

With my signature below, I certify that the above-named employee has been provided with the membership criteria for the CalSTRS Defined Benefit Program, and if applicable, was informed within 30 days of hire that they may elect membership in the Program at any time while employed. (Education Code section 22455.5).

OFFICIAL’S SIGNATURE	TITLE
COUNTY (or Other Employing Agency)	DISTRICT

PERMISSIVE MEMBERSHIP • REV 06/11