Form PERS-MSD-371 "Request for Service Credit Cost Information - Leave of Absence" - California

What Is Form PERS-MSD-371?

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-371 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-371 "Request for Service Credit Cost Information - Leave of Absence" - California

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Request for Service Credit Cost Information —
Leave of Absence
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
Member Mailing Address
you purchase service credit,
the lower your cost will be.
City
State
ZIP Code
(
)
Any balance resulting from
Daytime Phone
Email Address
an 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)
Purchase early so you have
Have you ever been a member of a public retirement system in California other than CalPERS?
enough time to pay the balance
No
Yes
c
c
in full by your retirement
Name of System(s)
date, or your retirement
If yes, have you purchased the service being requested in that retirement system?
No
Yes
c
c
benefit will be reduced by
the actuarial equivalent of
your remaining balance.
Leave of Absence Employment Information
Section 2
Provide the name of the
Employer
employer that granted
the leave.
Type of Leave (Select one that applies to the dates below):
Maternity/Paternity
Temporary Disability
c
c
List the dates and select
Educational
Serious Illness*
c
c
the type of leave for each
Sabbatical
Service
c
c
Name of Non-Profit or Governmental Organization
period requested.
Dates of Leave From (mm/dd/yyyy)
To (mm/dd/yyyy)
If you need more space
Type of Leave (Select one that applies to the dates below):
to enter additional leaves of
Maternity/Paternity
Temporary Disability
absence, please attach
c
c
Educational
Serious Illness*
a separate sheet.
c
c
Sabbatical
Service
c
c
Name of Non-Profit or Governmental Organization
If you have established
reciprocity or have an
Dates of Leave From (mm/dd/yyyy)
To (mm/dd/yyyy)
approved final compensation
Type of Leave (Select one that applies to the dates below):
exchange, we will contact
Maternity/Paternity
Temporary Disability
c
c
the retirement system to
Educational
Serious Illness*
c
c
determine your highest pay
Sabbatical
Service
c
c
rate, which can be used in
Name of Non-Profit or Governmental Organization
the calculation of your Leave
of Absence service credit.
Dates of Leave From (mm/dd/yyyy)
To (mm/dd/yyyy)
* “Serious Illness” is an employer-approved leave of absence granted for the member’s own serious illness or injury.
PERS-MSD-371 (11/19)
Page 1 of 3
Request for Service Credit Cost Information —
Leave of Absence
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
Member Mailing Address
you purchase service credit,
the lower your cost will be.
City
State
ZIP Code
(
)
Any balance resulting from
Daytime Phone
Email Address
an 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)
Purchase early so you have
Have you ever been a member of a public retirement system in California other than CalPERS?
enough time to pay the balance
No
Yes
c
c
in full by your retirement
Name of System(s)
date, or your retirement
If yes, have you purchased the service being requested in that retirement system?
No
Yes
c
c
benefit will be reduced by
the actuarial equivalent of
your remaining balance.
Leave of Absence Employment Information
Section 2
Provide the name of the
Employer
employer that granted
the leave.
Type of Leave (Select one that applies to the dates below):
Maternity/Paternity
Temporary Disability
c
c
List the dates and select
Educational
Serious Illness*
c
c
the type of leave for each
Sabbatical
Service
c
c
Name of Non-Profit or Governmental Organization
period requested.
Dates of Leave From (mm/dd/yyyy)
To (mm/dd/yyyy)
If you need more space
Type of Leave (Select one that applies to the dates below):
to enter additional leaves of
Maternity/Paternity
Temporary Disability
absence, please attach
c
c
Educational
Serious Illness*
a separate sheet.
c
c
Sabbatical
Service
c
c
Name of Non-Profit or Governmental Organization
If you have established
reciprocity or have an
Dates of Leave From (mm/dd/yyyy)
To (mm/dd/yyyy)
approved final compensation
Type of Leave (Select one that applies to the dates below):
exchange, we will contact
Maternity/Paternity
Temporary Disability
c
c
the retirement system to
Educational
Serious Illness*
c
c
determine your highest pay
Sabbatical
Service
c
c
rate, which can be used in
Name of Non-Profit or Governmental Organization
the calculation of your Leave
of Absence service credit.
Dates of Leave From (mm/dd/yyyy)
To (mm/dd/yyyy)
* “Serious Illness” is an employer-approved leave of absence granted for the member’s own serious illness or injury.
PERS-MSD-371 (11/19)
Page 1 of 3
Put your name and Social
Security number or CalPERS ID
Your Name
Social Security Number or CalPERS ID
at the top of every page
Member Certification
Section 3
Temporary Disability Leave:
I hereby certify under penalty of perjury the above information is true and correct to the best of my knowledge.
The employer must complete
I understand I must meet the requirements under California law. I have reviewed the publication A Guide to Your
Section 4 and also route the
CalPERS Service Credit Purchase Options (PUB 12) and I meet all the requirements outlined in the publication.
form to the member’s
I understand it is my responsibility to ensure this form is received by CalPERS. I further understand any balance
workers’ compensation
resulting from an election must be paid in full by my retirement date, or my retirement benefit will be reduced by
carrier to complete
the actuarial equivalent of the remaining balance.
Sections 5 and 6.
Member Signature
Date (mm/dd/yyyy)
Next Step: For all types of leave, give the form to the employer that granted the leave to complete Section 4 of this request form.
Leave of Absence Employer Certification
Section 4
Dates and type of
Reminder: If the employee has indicated a retirement date in Section 1, it is imperative that CalPERS receive this
completed Leave of Absence Employer Certification section promptly. Delays in receiving this information from your
leave in this section must
agency could affect the employee’s ability to make their election prior to retirement.
be completed by the
employer independently
Type of Leave (Select one that applies to the dates below):
of what the member
Maternity/Paternity
Temporary Disability
c
c
reports in Section 2.
Educational
Serious Illness*
c
c
Sabbatical
Service
c
c
Name of Non-Profit or Governmental Organization
Dates of Leave From (mm/dd/yyyy)
To (mm/dd/yyyy)
Type of Leave (Select one that applies to the dates below):
Maternity/Paternity
Temporary Disability
c
c
Educational
Serious Illness*
c
c
Sabbatical
Service
c
c
Name of Non-Profit or Governmental Organization
Dates of Leave From (mm/dd/yyyy)
To (mm/dd/yyyy)
Type of Leave (Select one that applies to the dates below):
Maternity/Paternity
Temporary Disability
c
c
Educational
Serious Illness*
c
c
Sabbatical
Service
c
c
Name of Non-Profit or Governmental Organization
Dates of Leave From (mm/dd/yyyy)
To (mm/dd/yyyy)
* “Serious Illness” is an employer-approved leave of absence granted for the member’s own serious illness or injury.
Employer: Return the
I hereby certify that the above information is true and correct. I understand this provides CalPERS with the
information required to assess eligibility, calculate the cost, and determine the amount of purchasable service
completed form to the
credit. I understand there is employer liability associated with this service credit purchase.
member or, for temporary
disability leave, forward it
to the member’s workers’
Employer Signature
Title
Date (mm/dd/yyyy)
compensation carrier
(
)
(
)
(see Section 5).
Printed Name
Daytime Phone
Fax
PERS-MSD-371 (11/19)
Page 2 of 3
Put your name and Social
Security number or CalPERS ID
Your Name
Social Security Number or CalPERS ID
at the top of every page
Temporary Disability Leave of Absence Certification
Section 5
To be completed by the
Workers’ Compensation Carrier Information
workers’ compensation
carrier that provides
Name of Employer’s Disability Carrier
temporary disability benefits.
Carrier’s Address
If the member had more
than one temporary
Employee’s Claim Number
Beginning Date of Temporary Disability Payments (mm/dd/yyyy)
Ending Date of Payments (mm/dd/yyyy)
disability leave period,
Effective Date of Permanent Disability Rating (mm/dd/yyyy)
provide claim numbers
and dates for each.
Was there a settlement by Compromise and Release?
No
Yes
If yes, you must provide a copy to CalPERS.
c
c
Signature of Authorized Workers’ Compensation Carrier Representative
Section 6
I hereby certify that the above information is true and correct. I understand this form provides CalPERS
Please return this request
with the information required to determine eligibility and calculate the applicable service credit cost(s).
form to the member.
Carrier Representative Signature
Date (mm/dd/yyyy)
Printed Name
Title
(
)
Daytime Phone
Mail to:
CalPERS Member Account Management Division
P.O. Box 4000, Sacramento, California 95812-4000
PERS-MSD-371 (11/19)
Page 3 of 3
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
Page of 4