Form PERS-MSD-369A "Request for Service Credit Information - Military Leave of Absence Service" - California

What Is Form PERS-MSD-369A?

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-369A 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-369A "Request for Service Credit Information - Military Leave of Absence Service" - California

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Request for Service Credit Information —
Military Leave of Absence Service
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
Any balance resulting from
Member Mailing Address
an election must be paid in
full by your retirement date.
City
State
ZIP Code
(
)
Purchase early so you have
Daytime Phone
Email Address
enough time to pay the balance
in full by your retirement
Have you submitted a retirement application?
No
Yes
c
c
Retirement Date (mm/dd/yyyy)
date, or your retirement
Have you ever been a member of a public retirement system in California other than CalPERS?
benefit will be reduced by
the actuarial equivalent of
No
Yes
c
c
Name of System(s)
your remaining balance.
If yes, have you purchased the service being requested in that retirement system?
No
Yes
c
c
Were you employed by a CalPERS-covered employer and granted a leave of absence to enter the military?
No
Yes
c
c
If no, please complete and submit the applicable form, Request for Service Credit Cost Information—
Military Service.
Member Certification
Section 2
I hereby certify under penalty of perjury the above information is true and correct to the best of my knowledge.
Attach a copy of your
I understand I must meet the requirements under California law. I have reviewed the publication A Guide to Your
military discharge or leave
CalPERS Military Service Credit Options (PUB 15) and I meet all the requirements outlined in the publication.
of absence documents
I understand it is my responsibility to ensure this form is received by CalPERS. I further understand any balance
(i.e., DD-214).
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.
Sign and date the request
form. Make a copy for
your records.
Member Signature
Date (mm/dd/yyyy)
Mail to:
CalPERS Member Account Management Division
P.O. Box 4000, Sacramento, California 95812-4000
PERS-MSD-369A (11/19)
Page 1 of 1
Request for Service Credit Information —
Military Leave of Absence Service
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
Any balance resulting from
Member Mailing Address
an election must be paid in
full by your retirement date.
City
State
ZIP Code
(
)
Purchase early so you have
Daytime Phone
Email Address
enough time to pay the balance
in full by your retirement
Have you submitted a retirement application?
No
Yes
c
c
Retirement Date (mm/dd/yyyy)
date, or your retirement
Have you ever been a member of a public retirement system in California other than CalPERS?
benefit will be reduced by
the actuarial equivalent of
No
Yes
c
c
Name of System(s)
your remaining balance.
If yes, have you purchased the service being requested in that retirement system?
No
Yes
c
c
Were you employed by a CalPERS-covered employer and granted a leave of absence to enter the military?
No
Yes
c
c
If no, please complete and submit the applicable form, Request for Service Credit Cost Information—
Military Service.
Member Certification
Section 2
I hereby certify under penalty of perjury the above information is true and correct to the best of my knowledge.
Attach a copy of your
I understand I must meet the requirements under California law. I have reviewed the publication A Guide to Your
military discharge or leave
CalPERS Military Service Credit Options (PUB 15) and I meet all the requirements outlined in the publication.
of absence documents
I understand it is my responsibility to ensure this form is received by CalPERS. I further understand any balance
(i.e., DD-214).
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.
Sign and date the request
form. Make a copy for
your records.
Member Signature
Date (mm/dd/yyyy)
Mail to:
CalPERS Member Account Management Division
P.O. Box 4000, Sacramento, California 95812-4000
PERS-MSD-369A (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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