The MSD 370 form is an important document for any individual with a mental health diagnosis. This form can be used to provide your doctor with detailed information about your condition, as well as help you track symptoms and treatment progress over time. Knowing what to expect when completing the MSD 370 can make the process simpler and more effective. In this blog post, we will provide an overview of the MSD 370 form and offer helpful tips for completing it.
| Question | Answer |
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| Form Name | Form Pers Msd 370 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | service prior to membership ceta service credit california form |
Request for Service Credit Cost Information — Service Prior to Membership, CETA, and Fellowship
888 CalPERS (or
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NameofMember(LastName,FirstName,MiddleInitial) |
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SocialSecurityNumberorCalPERSID |
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
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Former Name (if applicable) |
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Daytime Phone |
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Mailing Address |
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City |
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State |
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ZIP Code |
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Current Employer |
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Have you requested this cost information before? |
c No c Yes |
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Requested Date (mm/dd/yyyy) |
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Have you submitted a retirement application? |
c No |
c Yes |
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Retirement Date (mm/dd/yyyy) |
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Were you compensated for this employment? |
c No |
c Yes |
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Are you a member of a reciprocal agency? c No |
cYes Ifyes,whatagency? |
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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
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Was this service rendered under the Comprehensive Employment & Training Act from 1973 to 1982? |
c No c Yes |
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Was this service rendered under a fellowship program? |
c No c Yes |
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Name of Program |
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Was service rendered as a |
c Yes |
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Employment From (mm/dd/yyyy) |
To (mm/dd/yyyy) |
Location |
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Position Title |
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Hours Worked Per Month OR Time Base/Fraction of Full Time |
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Employment From (mm/dd/yyyy) |
To (mm/dd/yyyy) |
Location |
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Position Title |
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Hours Worked Per Month OR Time Base/Fraction of Full Time |
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Employment From (mm/dd/yyyy) |
To (mm/dd/yyyy) |
Location |
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Position Title |
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Hours Worked Per Month OR Time Base/Fraction of Full Time |
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Section 3 |
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Member Certification |
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Also attach a copy of your |
I hereby certify that the above information is true and correct. |
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cost estimate from the |
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Service Credit Cost Estimator |
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Signature |
Date (mm/dd/yyyy) |
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at www.calpers.ca.gov/
• IftheservicewasperformedfortheStateofCaliforniaoraCaliforniaStateUniversity,stop. Sign this form on the line
servicecreditestimator.
above and mail it to CalPERS.
•
Page 1 of 2 |
Put your name and Social |
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Security number or CalPERS ID |
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Your Name |
Social Security Number or CalPERS ID |
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at the top of every page |
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Section 4
If the service was performed for the State of California or California State University, employer
certification is not required.
Employer Certification
with all the necessary information to apply any exclusions to CalPERS membership? c No c Yes
Ifyes,continuetoSection6tocompleteemployercertiication.
Ifno,providethefollowinginformation:
Position Type |
c Seasonal |
c Limited Term |
c |
c Intermittent |
c Permanent |
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Position Title |
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Employment From (mm/dd/yyyy) |
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To (mm/dd/yyyy) |
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Time Base |
c Full time |
c Part time |
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c Hourly |
c Fraction of full time |
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Average Number of Days or Hours Per Month |
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c Days c Hours |
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Average Percentage or Fraction of Time Worked Per Month |
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ForTeachersAssistantsinacredentialprogramonly: |
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Was this person employed pursuant to Section 44926 of the Education Code? c No c Yes |
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Ifapplicable,completeSection5,orelsecontinuetoSection6tocompleteemployercertiication. |
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Section 5 |
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Member Employment History (Fill in below or attach separate sheet) |
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Complete Section 5 |
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Employment From (mm/dd/yyyy) |
Employment To (mm/dd/yyyy) |
Position Title |
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only if the employee was |
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full time, worked more than |
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1,000 hours in a fiscal year |
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Pay Rate (Hourly/Daily/Monthly) |
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Time Worked (Hours Per Day) |
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Time Worked (Earnings) |
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(July 1 through June 30), or |
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did not work a consistent |
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Employment From (mm/dd/yyyy) |
Employment To (mm/dd/yyyy) |
Position Title |
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time base and could not |
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be listed above. |
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Pay Rate (Hourly/Daily/Monthly) |
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Time Worked (Hours Per Day) |
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Time Worked (Earnings) |
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Employment From (mm/dd/yyyy) |
Employment To (mm/dd/yyyy) |
Position Title |
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Pay Rate (Hourly/Daily/Monthly) |
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Time Worked (Hours Per Day) |
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Time Worked (Earnings) |
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Employment From (mm/dd/yyyy) |
Employment To (mm/dd/yyyy) |
Position Title |
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Pay Rate (Hourly/Daily/Monthly) |
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Time Worked (Hours Per Day) |
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Time Worked (Earnings) |
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Continue to Section 6. |
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Section 6 |
Statement and Signature of Personnel or Payroll Officer |
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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. informationitneedstodetermineandapplyallappropriateservicecredits,andthatthereisapotentialfor
employer liability if this certification results in a change in employment history relied upon by CalPERS.
SignatureTitleDate (mm/dd/yyyy)
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Printed Name |
Daytime Phone |
Fax |
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Mail to: |
CalPERS Customer Account Services Division • |
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Page 2 of 2 |