Form PERS-MSD-353 "Tier Conversion Cost Information Request" - California

What Is Form PERS-MSD-353?

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-MSD-353 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-MSD-353 "Tier Conversion Cost Information Request" - California

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Tier Conversion Cost Information Request
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
About You
Section 1
The earlier in your career you
Member Address
purchase service credit, the
lower your cost will be.
City
State
ZIP Code
Any balance resulting from an
(
)
Daytime Phone
Email Address
election must be paid in full
by your retirement date.
Have you submitted a retirement application?
No
Yes
c
c
Retirement Date (mm/dd/yyyy)
Convert your service early
so you have enough time
to pay the balance in full
by your retirement date
or your retirement benefit
will be reduced by the
actuarial equivalent of the
remaining balance.
Member Certification
Section 2
I hereby certify under penalty of perjury the above information is true and correct to the best of my knowledge.
Sign and date the request
I understand I must meet the requirements under California law. I have reviewed the publication A Guide to Your
form. Make a copy for
CalPERS Service Credit Purchase Options (PUB 12) and I meet all the requirements outlined in the publication.
your records.
I understand it is my responsibility to ensure this form is received by CalPERS. I further understand any balance
resulting from an election must be paid in full by my retirement date, or my retirement benefit will be reduced by
the actuarial equivalent of the remaining balance.
Signature
Date (mm/dd/yyyy)
Mail to:
CalPERS Member Account Management Division
P.O. Box 4000, Sacramento, California 95812-4000
PERS-MSD-353 (11/19)
Page 1 of 1
Tier Conversion Cost Information Request
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
About You
Section 1
The earlier in your career you
Member Address
purchase service credit, the
lower your cost will be.
City
State
ZIP Code
Any balance resulting from an
(
)
Daytime Phone
Email Address
election must be paid in full
by your retirement date.
Have you submitted a retirement application?
No
Yes
c
c
Retirement Date (mm/dd/yyyy)
Convert your service early
so you have enough time
to pay the balance in full
by your retirement date
or your retirement benefit
will be reduced by the
actuarial equivalent of the
remaining balance.
Member Certification
Section 2
I hereby certify under penalty of perjury the above information is true and correct to the best of my knowledge.
Sign and date the request
I understand I must meet the requirements under California law. I have reviewed the publication A Guide to Your
form. Make a copy for
CalPERS Service Credit Purchase Options (PUB 12) and I meet all the requirements outlined in the publication.
your records.
I understand it is my responsibility to ensure this form is received by CalPERS. I further understand any balance
resulting from an election must be paid in full by my retirement date, or my retirement benefit will be reduced by
the actuarial equivalent of the remaining balance.
Signature
Date (mm/dd/yyyy)
Mail to:
CalPERS Member Account Management Division
P.O. Box 4000, Sacramento, California 95812-4000
PERS-MSD-353 (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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