Form PERS-MSD-370A "Request for Service Credit Cost Information - Comprehensive Employment & Training Act (Ceta) or Fellowship" - California

What Is Form PERS-MSD-370A?

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-370A 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-370A "Request for Service Credit Cost Information - Comprehensive Employment & Training Act (Ceta) or Fellowship" - California

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Request for Service Credit Cost Information —
Comprehensive Employment & Training Act (CETA)
or Fellowship
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
(
)
an election must be paid in
Daytime Phone
Email Address
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.
CETA or Fellowship Employment Information
Section 2
Provide the name of
Employer
the employer where the
service was earned.
Comprehensive Employment & Training Act 1973 to 1982
c
The employer must be a
Fellowship Program
c
CalPERS-covered agency.
Name of Program
List the dates and
Employment From (mm/dd/yyyy)
To (mm/dd/yyyy)
Location
employment location
for which you are
Employment From (mm/dd/yyyy)
To (mm/dd/yyyy)
Location
requesting credit.
Employment From (mm/dd/yyyy)
To (mm/dd/yyyy)
Location
Member Certification
Section 3
I hereby certify under penalty of perjury the above information is true and correct to the best of my knowledge.
If the service was
I understand I must meet the requirements under California law. I have reviewed the publication A Guide to Your
performed for the State of
CalPERS Service Credit Purchase Options (PUB 12) and I meet all the requirements outlined in the publication.
California or a California
I understand it is my responsibility to ensure this form is received by CalPERS. I further understand any balance
State University, sign
resulting from an election must be paid in full by my retirement date, or my retirement benefit will be reduced by
this form and mail it to
the actuarial equivalent of the remaining balance.
CalPERS, P.O. Box 4000,
Sacramento, CA
95812-4000.
Member Signature
Date (mm/dd/yyyy)
If the service was performed for the University of California prior to October 1, 1963, a CalPERS-covered public
agency, or a school, forward this form to the appropriate employer for completion of pages 2–4 before returning
to CalPERS.
If you have established reciprocity or have an approved final compensation exchange, we will contact the
retirement system to determine your highest pay rate, which can be used in the calculation of your CETA
or Fellowship service credit.
PERS-MSD-370A (11/19)
Page 1 of 4
Request for Service Credit Cost Information —
Comprehensive Employment & Training Act (CETA)
or Fellowship
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
(
)
an election must be paid in
Daytime Phone
Email Address
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.
CETA or Fellowship Employment Information
Section 2
Provide the name of
Employer
the employer where the
service was earned.
Comprehensive Employment & Training Act 1973 to 1982
c
The employer must be a
Fellowship Program
c
CalPERS-covered agency.
Name of Program
List the dates and
Employment From (mm/dd/yyyy)
To (mm/dd/yyyy)
Location
employment location
for which you are
Employment From (mm/dd/yyyy)
To (mm/dd/yyyy)
Location
requesting credit.
Employment From (mm/dd/yyyy)
To (mm/dd/yyyy)
Location
Member Certification
Section 3
I hereby certify under penalty of perjury the above information is true and correct to the best of my knowledge.
If the service was
I understand I must meet the requirements under California law. I have reviewed the publication A Guide to Your
performed for the State of
CalPERS Service Credit Purchase Options (PUB 12) and I meet all the requirements outlined in the publication.
California or a California
I understand it is my responsibility to ensure this form is received by CalPERS. I further understand any balance
State University, sign
resulting from an election must be paid in full by my retirement date, or my retirement benefit will be reduced by
this form and mail it to
the actuarial equivalent of the remaining balance.
CalPERS, P.O. Box 4000,
Sacramento, CA
95812-4000.
Member Signature
Date (mm/dd/yyyy)
If the service was performed for the University of California prior to October 1, 1963, a CalPERS-covered public
agency, or a school, forward this form to the appropriate employer for completion of pages 2–4 before returning
to CalPERS.
If you have established reciprocity or have an approved final compensation exchange, we will contact the
retirement system to determine your highest pay rate, which can be used in the calculation of your CETA
or Fellowship service credit.
PERS-MSD-370A (11/19)
Page 1 of 4
Put your name and Social
Security number or CalPERS ID
Member Name
Social Security Number or CalPERS ID
at the top of every page
Employer Certification
Section 4
Reminder:
If the service was
If the employee has indicated a retirement date in Section 1, it is imperative that CalPERS receive this
performed for the State of
completed Employer Certification section and Pay Period Detail in Section 5 promptly. Delays in receiving this information
California or California
from your agency could affect the employee’s ability to make their election prior to retirement.
State University, employer
Was this service rendered under the Comprehensive Employment & Training Act
certification is not required.
from 1973 to 1982?
No
Yes
c
c
Was this service rendered under a fellowship program?
No
Yes
c
c
Name of Program
CETA or Fellowship Pay Period Detail
Section 5
Complete the required
Employer Name
Pay Period Detail for the
requested time period.
Please complete all sections for the period(s) this person was employed by your agency. You must provide service
After completing
period dates, position titles, pay rates, hours worked, and earnings for each pay period. Please indicate any
Sections 4–5 and before
overtime, special compensation, and holiday pay in a separate row. Also, indicate if the employee was subject
submitting these forms
to mandatory furloughs by pay period.
to CalPERS, provide
Government Code section 20221 specifies employers are required to furnish CalPERS with
copies of this form to:
information requested.
• your payroll/fiscal
department,
For help completing this form, visit www.calpers.ca.gov to view Circular Letters concerning employer
• the employee, and
certification guidelines.
• your own agency’s
Appointment Tenure
records.
Permanent
Indeterminate
Seasonal
c
c
c
Term End Date (mm/dd/yyyy)
Temporary
Other (Explain):
c
c
Term End Date (mm/dd/yyyy)
Check the box for the classification of the employment period(s) being requested. Then, provide the dates,
or indicate all, for the employment period(s) of the classification(s) selected:
Classification
Applicable Employment Period
School Miscellaneous
c
Employment From (mm/dd/yyyy)
To (mm/dd/yyyy)
Local Miscellaneous
c
Employment From (mm/dd/yyyy)
To (mm/dd/yyyy)
Local Safety – Other
c
Employment From (mm/dd/yyyy)
To (mm/dd/yyyy)
Local Safety – Fire
c
Employment From (mm/dd/yyyy)
To (mm/dd/yyyy)
Local Safety – Police
c
Employment From (mm/dd/yyyy)
To (mm/dd/yyyy)
PERS-MSD-370A (11/19)
Page 2 of 4
Put your name and Social
Security number or CalPERS ID
Member Name
Social Security Number or CalPERS ID
at the top of every page
CETA or Fellowship Pay Period Detail
Section 5,
continued
Please keep this information attached to the Request for Service Credit Cost Information.
A fillable version of this form is available at www.calpers.ca.gov/docs/forms-publications/ceta-fellowship.pdf.
Full-Time
Time Base
Months
Pay Rate
Total Hours
Start Date
End Date
per Year
(Full Time/
Worked
Position Title
Earnings
(mm/dd/yyyy)
(mm/dd/yyyy)
(Hourly/Daily/Monthly)
Part Time)
(10, 11, 12)
Examples:
01/01/1980
06/30/1980
Office Technician
$6.00 hourly
426 total
$2,556 total
PT
N/A
07/01/1999
07/31/1999
Fellow
$2,000 monthly
$2,000
FT
N/A
Continue on the next page if necessary.
Statement and Signature of Personnel or Payroll Officer
Required: By signing, I certify the following:
1.
The information provided in Sections 4 and 5 is true, complete, and correct to the best of my knowledge and belief;
2.
I am an authorized representative of the agency named in Section 5 and am qualified to certify this form;
3.
I understand this form provides CalPERS with the information required to assess eligibility, calculate the cost, and determine
the amount of purchasable service credit that, if elected, will be included in the member’s retirement calculation;
4.
I understand the agency named in Section 5 is accepting any employer liability associated with this service credit purchase.
Signature
Title
Date (mm/dd/yyyy)
(
)
(
)
Printed Name
Business Phone
Fax
Email
Mail to:
CalPERS Member Account Management Division
P.O. Box 4000, Sacramento, California 95812-4000
PERS-MSD-370A (11/19)
Page 3 of 4
Put your name and Social
Security number or CalPERS ID
Member Name
Social Security Number or CalPERS ID
at the top of every page
CETA or Fellowship Pay Period Detail
Section 5,
continued
A fillable version of this form is available at www.calpers.ca.gov/docs/forms-publications/ceta-fellowship.pdf.
Full-Time
Time Base
Months
Pay Rate
Total Hours
Start Date
End Date
per Year
(Full Time/
Worked
Position Title
Earnings
(mm/dd/yyyy)
(mm/dd/yyyy)
(Hourly/Daily/Monthly)
Part Time)
(10, 11, 12)
Mail to:
CalPERS Member Account Management Division
P.O. Box 4000, Sacramento, California 95812-4000
PERS-MSD-370A (11/19)
Page 4 of 4
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 5