Form Pers Msd 370 PDF Details

Understanding the complexities of preparing for retirement, especially in the context of public employment, requires a keen awareness of the importance of service credits. Among the various forms and documents that play a crucial role in this process, the PERS MSD 370 form stands out as a vital tool for individuals seeking to obtain cost information for service credit related to periods of work prior to membership, as well as those covered under special programs like the CETA and fellowships. Designed to streamline the process of requesting and calculating the cost of purchasing additional service credits, this form acts as a bridge between the employee and CalPERS, ensuring that all necessary details, from personal information to detailed employment history, are accurately captured. It not only serves as a formal request to initiate the evaluation of service credits but also as a certification of the authenticity and accuracy of the information provided by the member, thereby triggering a series of assessments aimed at determining how these previous periods of employment can influence and enhance retirement benefits. The structure of the form is methodically organized into sections that guide the member through a step-by-step process, from personal identification to employer verification, culminating in a certification that attests to the truthfulness and completeness of the data submitted. This systematic approach simplifies the otherwise daunting task of navigating the intricacies of retirement planning, highlighting the importance of accuracy, completeness, and compliance with procedural requirements to secure a financially stable future.

QuestionAnswer
Form NameForm Pers Msd 370
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesservice prior to membership ceta service credit california form

Form Preview Example

Request for Service Credit Cost Information — Service Prior to Membership, CETA, and Fellowship

888 CalPERS (or 888-225-7377) •฀TTY: (877) 249-7442

 

 

 

 

Name฀of฀Member฀(Last฀Name,฀First฀Name,฀Middle฀Initial)฀

฀

฀

Social฀Security฀Number฀or฀CalPERS฀ID

Section 1

If we have provided cost information to you in the past for this service credit, check the Yes box and indicate the date you submitted your request. If you have submitted a retirement application, check the Yes box and indicate your planned retirement date.

About You

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Former Name (if applicable)

 

 

 

Daytime Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

State

 

 

ZIP Code

 

 

 

Current Employer

Have you requested this cost information before?

c No c Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Requested Date (mm/dd/yyyy)

Have you submitted a retirement application?

c No

c Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Retirement Date (mm/dd/yyyy)

Were you compensated for this employment?

c No

c Yes

 

 

 

 

 

 

 

 

 

Are you a member of a reciprocal agency? c No

c฀Yes฀ If฀yes,฀what฀agency?

 

 

 

 

 

 

 

 

 

 

 

Section 2

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 hours of employment for which you are requesting credit. List each position separately and indicate if service was full time or part time.

If the service was part time, show service as a fraction or list the hours (e.g., 20 hours per month or half time).

Prior Employment Information

Employer

Address

City

 

 

State

ZIP Code

Was this service rendered under the Comprehensive Employment & Training Act from 1973 to 1982?

c No c Yes

Was this service rendered under a fellowship program?

c No c Yes

 

 

 

 

Name of Program

Was service rendered as a 10-month employee? c No

c Yes

 

 

 

 

 

 

 

 

 

 

 

Employment From (mm/dd/yyyy)

To (mm/dd/yyyy)

Location

 

 

 

 

 

 

 

 

 

 

Position Title

 

Hours Worked Per Month OR Time Base/Fraction of Full Time

 

 

 

 

 

 

 

 

 

 

Employment From (mm/dd/yyyy)

To (mm/dd/yyyy)

Location

 

 

 

 

 

 

 

 

 

 

Position Title

 

Hours Worked Per Month OR Time Base/Fraction of Full Time

 

 

 

 

 

 

 

 

 

 

Employment From (mm/dd/yyyy)

To (mm/dd/yyyy)

Location

 

 

 

 

 

 

 

 

 

 

Position Title

 

Hours Worked Per Month OR Time Base/Fraction of Full Time

 

Section 3

 

Member Certification

 

 

Also attach a copy of your

I hereby certify that the above information is true and correct.

 

 

cost estimate from the

 

 

Service Credit Cost Estimator

 

 

 

 

Signature

Date (mm/dd/yyyy)

 

 

 

at www.calpers.ca.gov/

•฀ If฀the฀service฀was฀performed฀for฀the฀State฀of฀California฀or฀a฀California฀State฀University,฀stop. Sign this form on the line

servicecreditestimator.

above and mail it to CalPERS.

•฀ If฀the฀service฀was฀performed฀for฀the฀University฀of฀California,฀a฀CalPERS-covered฀public฀agency,฀or฀a฀school,฀forward฀this฀ request form to the appropriate employer for completion of Page 2 before returning to CalPERS.

PERS-MSD-370 (11/13)

Page 1 of 2

Put your name and Social

 

 

Security number or CalPERS ID

 

 

Your Name

Social Security Number or CalPERS ID

 

at the top of every page

 

 

Section 4

If the service was performed for the State of California or California State University, employer

certification is not required.

Employer Certification

Do฀you฀agree฀that฀the฀member-provided฀information฀in฀Section฀2฀is฀true,฀correct,฀and฀provides฀CalPERS฀

with all the necessary information to apply any exclusions to CalPERS membership? c No c Yes

If฀yes,฀continue฀to฀Section฀6฀to฀complete฀employer฀certiication.

If฀no,฀provide฀the฀following฀information:

Position Type

c Seasonal

c Limited Term

c On-call

c Intermittent

c Permanent

 

 

 

Position Title

 

 

 

 

Employment From (mm/dd/yyyy)

 

To (mm/dd/yyyy)

 

 

 

Time Base

c Full time

c Part time

 

c Hourly

c Fraction of full time

 

 

 

Average Number of Days or Hours Per Month

 

 

 

 

 

c Days c Hours

 

 

 

Average Percentage or Fraction of Time Worked Per Month

 

 

 

 

 

 

 

 

 

 

 

 

 

For฀Teachers฀Assistants฀in฀a฀credential฀program฀only:

 

 

 

 

 

 

 

 

Was this person employed pursuant to Section 44926 of the Education Code? c No c Yes

 

 

 

If฀applicable,฀complete฀Section฀5,฀or฀else฀continue฀to฀Section฀6฀to฀complete฀employer฀certiication.

 

 

 

 

 

 

 

 

 

Section 5

 

Member Employment History (Fill in below or attach separate sheet)

 

 

 

Complete Section 5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employment From (mm/dd/yyyy)

Employment To (mm/dd/yyyy)

Position Title

 

 

 

 

only if the employee was

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

full time, worked more than

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1,000 hours in a fiscal year

 

Pay Rate (Hourly/Daily/Monthly)

 

 

 

Time Worked (Hours Per Day)

 

Time Worked (Earnings)

 

 

 

 

 

 

 

 

 

 

 

 

(July 1 through June 30), or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

did not work a consistent

 

Employment From (mm/dd/yyyy)

Employment To (mm/dd/yyyy)

Position Title

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

time base and could not

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

be listed above.

 

Pay Rate (Hourly/Daily/Monthly)

 

 

 

Time Worked (Hours Per Day)

 

Time Worked (Earnings)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employment From (mm/dd/yyyy)

Employment To (mm/dd/yyyy)

Position Title

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pay Rate (Hourly/Daily/Monthly)

 

 

 

Time Worked (Hours Per Day)

 

Time Worked (Earnings)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employment From (mm/dd/yyyy)

Employment To (mm/dd/yyyy)

Position Title

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pay Rate (Hourly/Daily/Monthly)

 

 

 

Time Worked (Hours Per Day)

 

Time Worked (Earnings)

 

 

 

Continue to Section 6.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section 6

Statement and Signature of Personnel or Payroll Officer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please return this form I hereby certify that the above information is true and correct. I understand this provides CalPERS with the

to the member. information฀it฀needs฀to฀determine฀and฀apply฀all฀appropriate฀service฀credits,฀and฀that฀there฀is฀a฀potential฀for฀

employer liability if this certification results in a change in employment history relied upon by CalPERS.

SignatureTitleDate (mm/dd/yyyy)

 

(

)

 

 

 

Printed Name

Daytime Phone

Fax

Mail to:

CalPERS Customer Account Services Division • P.O.฀Box฀4000,฀Sacramento,฀California฀95812-4000

 

 

PERS-MSD-370 (11/13)

Page 2 of 2

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