Form PERS-BSD-145 "Reinstatement From Service Retirement Application" - California

What Is Form PERS-BSD-145?

This is a legal form that was released by the California Public Employees' Retirement System - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2019;
  • The latest edition provided by the California Public Employees' Retirement System;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form PERS-BSD-145 by clicking the link below or browse more documents and templates provided by the California Public Employees' Retirement System.

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Download Form PERS-BSD-145 "Reinstatement From Service Retirement Application" - California

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Reinstatement From Service
Retirement Application
888 CalPERS (or 888-225-7377)
TTY: (877) 249-7442
By completing this form you are requesting to reinstate into active membership with a CalPERS-covered employer.
Prior CalPERS approval is not required. You must notify us immediately if your first day of compensated employment
changes. For important information about how reinstatement can affect your retirement benefits, refer to the publication
Reinstatement From Retirement (PUB 37).
Information About You
Section 1
Please provide your name
Your Name (First Name, Middle Initial, Last Name)
CalPERS ID or Social Security Number
as it appears on your
(
)
(
)
Social Security card.
Birth Date (mm/dd/yyyy)
Daytime Phone
Alternate Phone
Address
City
State
ZIP
Employer Information
Section 2
Employee’s Start Date is
Employee’s Start Date (mm/dd/yyyy)
Employee’s Job Title (do not abbreviate)
the day the member
starts employment.
Name of Employer
CalPERS Business Partner ID
(
)
(
)
Employer Phone
Employer Fax
Employer Email
Address
City
State
ZIP
Employer Certification
I hereby certify, under penalty of perjury, that the above information is true, complete, and correct
to the best of my knowledge.
Authorized Employer Signature
Date (mm/dd/yyyy
Print Name
Title
Your Signature and Certification
Section 3
I understand that reinstatement will terminate my current CalPERS retirement benefit and can change
the benefits I am entitled to receive in the future when I re-retire.
Your Signature
Date (mm/dd/yyyy)
Mail to:
CalPERS Retirement Benefit Services Division
P.O. Box 942711, Sacramento, California 94229-2711
PERS-BSD-145 (11/19)
Page 1 of 1
Reinstatement From Service
Retirement Application
888 CalPERS (or 888-225-7377)
TTY: (877) 249-7442
By completing this form you are requesting to reinstate into active membership with a CalPERS-covered employer.
Prior CalPERS approval is not required. You must notify us immediately if your first day of compensated employment
changes. For important information about how reinstatement can affect your retirement benefits, refer to the publication
Reinstatement From Retirement (PUB 37).
Information About You
Section 1
Please provide your name
Your Name (First Name, Middle Initial, Last Name)
CalPERS ID or Social Security Number
as it appears on your
(
)
(
)
Social Security card.
Birth Date (mm/dd/yyyy)
Daytime Phone
Alternate Phone
Address
City
State
ZIP
Employer Information
Section 2
Employee’s Start Date is
Employee’s Start Date (mm/dd/yyyy)
Employee’s Job Title (do not abbreviate)
the day the member
starts employment.
Name of Employer
CalPERS Business Partner ID
(
)
(
)
Employer Phone
Employer Fax
Employer Email
Address
City
State
ZIP
Employer Certification
I hereby certify, under penalty of perjury, that the above information is true, complete, and correct
to the best of my knowledge.
Authorized Employer Signature
Date (mm/dd/yyyy
Print Name
Title
Your Signature and Certification
Section 3
I understand that reinstatement will terminate my current CalPERS retirement benefit and can change
the benefits I am entitled to receive in the future when I re-retire.
Your Signature
Date (mm/dd/yyyy)
Mail to:
CalPERS Retirement Benefit Services Division
P.O. Box 942711, Sacramento, California 94229-2711
PERS-BSD-145 (11/19)
Page 1 of 1
Privacy Notice
The privacy of personal information is of the utmost importance to CalPERS.
The following information is provided to you in compliance with the Information
Practices Act of 1977 and the Federal Privacy Act of 1974.
Information Purpose
Social Security numbers are used for the
following purposes:
The information requested is collected pursuant
1.
Enrollee identification
to the Government Code (sections 20000 et seq.)
2. Payroll deduction/state contributions
and will be used for administration of Board
3. Billing of contracting agencies for employee/
duties under the Retirement Law, the Social
employer contributions
Security Act, and the Public Employees’ Medical
4. Reports to CalPERS and other state agencies
and Hospital Care Act, as the case may be.
5. Coordination of benefits among carriers
Submission of the requested information is
6. Resolving member appeals, complaints,
mandatory. Failure to comply may result in
or grievances with health plan carriers
CalPERS being unable to perform its functions
regarding your status.
Information Disclosure
Please do not include information that is
Portions of this information may be transferred
not requested.
to other state agencies (such as your employer),
physicians, and insurance carriers, but only
Social Security Numbers
in strict accordance with current statutes
regarding confidentiality.
Social Security numbers are collected on a
mandatory and voluntary basis. If this is CalPERS’
Your Rights
first request for disclosure of your Social Security
number, then disclosure is mandatory. If your
You have the right to review your membership
Social Security number has already been provided,
files maintained by the System. For questions
disclosure is voluntary. Due to the use of Social
about this notice, our Privacy Policy, or your rights,
Security numbers by other agencies for
please write to the CalPERS Privacy Officer at
identification purposes, we may be unable to
400 Q Street, Sacramento, CA 95811 or call us
verify eligibility for benefits without the number.
at 888 CalPERS (or 888-225-7377).
May 2016
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