Form PERS-EAMD-139S "Notice of Exclusion From CalPERS Membership for State Agencies" - California

What Is Form PERS-EAMD-139S?

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 April 1, 2020;
  • 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-EAMD-139S 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-EAMD-139S "Notice of Exclusion From CalPERS Membership for State Agencies" - California

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California Public Employees’ Retirement System
P.O. Box 942715 Sacramento, CA 94229-2715
888 CalPERS (or 888-225-7377) | Fax: (800) 959-6545
TTY: (877) 249-7442 | www.calpers.ca.gov
NOTICE OF EXCLUSION FROM CalPERS MEMBERSHIP FOR STATE AGENCIES
Your employer is legislatively mandated to provide an employee benefit package which includes service retirement,
death, and disability benefits through the California Public Employees’ Retirement System (CalPERS) .
Section 1. Employee Information
Name: Last
First
Middle
DOB
CID
Section 2. Employer Information
Name of Department
Position Title
Term of Appointment
If Temporary, enter nearest number of whole months
Appointment Date
the appointment is expected to last.
Permanent
Temporary
Months
Time Base
Full Time
Intermittent
Indeterminate
Part Time, if part time enter the fraction of full time:
In your current position with this agency, you are excluded from CalPERS membership because:
1.
Your full time seasonal or limited term appointment is limited to six months or less.
2.
Your part time appointment is limited to less than an average of 20 hours per week for less than one year.
3.
Your appointment is an on call, intermittent, emergency, substitute, or other irregular basis which excludes
you from membership until you have worked 1,000 hours (or 125 days if paid on per diem basis) in a fiscal
year (July 1-June 30).
4.
Your position is excluded by law. Explain the exclusion that applies below:
5.
You are an independent contractor.
6.
You are a CalPERS retiree and have not reinstated from retirement.
NOTE: If you are a CalPERS member from previous employment and have not terminated membership (taken
a refund of your contributions and service credit) exclusions 1, 2, and 3 do not apply to you. You should qualify
for membership immediately in your current position. Please notify your employer to complete your enrollment
and report your employment to CalPERS.
If you believe your employment does qualify you for CalPERS membership, ask your employer to provide
you with an explanation. You can also contact CalPERS directly by sending a letter that provides the
reasons why you feel you should be a member to the Employer Account Management Division, P.O. Box
942709, Sacramento, CA 94229-2709.
Signature of Certifying Officer
Title
Date
Signature of Employee
Date
Note: Benefits provided by CalPERS are described in the “State Miscellaneous and Industrial Member Benefits
(PUB 6)” booklet, available on our website
.
www.calpers.ca.gov
The employer must retain this form in the employee’s file for auditing purposes.
PERS-EAMD-139S | Rev. 04/2020
California Public Employees’ Retirement System
P.O. Box 942715 Sacramento, CA 94229-2715
888 CalPERS (or 888-225-7377) | Fax: (800) 959-6545
TTY: (877) 249-7442 | www.calpers.ca.gov
NOTICE OF EXCLUSION FROM CalPERS MEMBERSHIP FOR STATE AGENCIES
Your employer is legislatively mandated to provide an employee benefit package which includes service retirement,
death, and disability benefits through the California Public Employees’ Retirement System (CalPERS) .
Section 1. Employee Information
Name: Last
First
Middle
DOB
CID
Section 2. Employer Information
Name of Department
Position Title
Term of Appointment
If Temporary, enter nearest number of whole months
Appointment Date
the appointment is expected to last.
Permanent
Temporary
Months
Time Base
Full Time
Intermittent
Indeterminate
Part Time, if part time enter the fraction of full time:
In your current position with this agency, you are excluded from CalPERS membership because:
1.
Your full time seasonal or limited term appointment is limited to six months or less.
2.
Your part time appointment is limited to less than an average of 20 hours per week for less than one year.
3.
Your appointment is an on call, intermittent, emergency, substitute, or other irregular basis which excludes
you from membership until you have worked 1,000 hours (or 125 days if paid on per diem basis) in a fiscal
year (July 1-June 30).
4.
Your position is excluded by law. Explain the exclusion that applies below:
5.
You are an independent contractor.
6.
You are a CalPERS retiree and have not reinstated from retirement.
NOTE: If you are a CalPERS member from previous employment and have not terminated membership (taken
a refund of your contributions and service credit) exclusions 1, 2, and 3 do not apply to you. You should qualify
for membership immediately in your current position. Please notify your employer to complete your enrollment
and report your employment to CalPERS.
If you believe your employment does qualify you for CalPERS membership, ask your employer to provide
you with an explanation. You can also contact CalPERS directly by sending a letter that provides the
reasons why you feel you should be a member to the Employer Account Management Division, P.O. Box
942709, Sacramento, CA 94229-2709.
Signature of Certifying Officer
Title
Date
Signature of Employee
Date
Note: Benefits provided by CalPERS are described in the “State Miscellaneous and Industrial Member Benefits
(PUB 6)” booklet, available on our website
.
www.calpers.ca.gov
The employer must retain this form in the employee’s file for auditing purposes.
PERS-EAMD-139S | Rev. 04/2020
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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