Form PERS-MSD-372 "Request for Service Credit Cost Information - Service Prior to Membership, Ceta, Fellowship, Layoff, Prior Service, and Optional Member Service" - California

What Is Form PERS-MSD-372?

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-372 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-372 "Request for Service Credit Cost Information - Service Prior to Membership, Ceta, Fellowship, Layoff, Prior Service, and Optional Member Service" - California

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Request for Service Credit Cost Information —
Service Prior to Membership, CETA, Fellowship,
Layoff, Prior Service, and Optional Member 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
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.
Employment Information
Section 2
List information about the
Employment From (mm/dd/yyyy)
Employment To (mm/dd/yyyy)
Employer
employer you worked for at
Type of Credit
Service Prior to Membership
CETA
Fellowship
the time of your service.
c
c
c
Layoff
Prior Service
Optional Member Service
c
c
c
Employment From (mm/dd/yyyy)
Employment To (mm/dd/yyyy)
Employer
Type of Credit
Service Prior to Membership
CETA
Fellowship
c
c
c
Layoff
Prior Service
Optional Member Service
c
c
c
Member Certification
Section 3
I hereby certify under penalty of perjury the above information is true and correct to the best of my knowledge.
Complete the Member
I understand I must meet the requirements under California law. I have reviewed the publication A Guide to Your
Certification section and
CalPERS Service Credit Purchase Options (PUB 12) and I meet all the requirements outlined in the publication.
forward this form to the
I understand it is my responsibility to ensure this form is received by CalPERS. I further understand any balance
appropriate employer
resulting from an election must be paid in full by my retirement date, or my retirement benefit will be reduced by
for completion of the
the actuarial equivalent of the remaining balance.
Employer Certification.
Member Signature
Date (mm/dd/yyyy)
PERS-MSD-372 (8/20)
Page 1 of 2
Request for Service Credit Cost Information —
Service Prior to Membership, CETA, Fellowship,
Layoff, Prior Service, and Optional Member 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
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.
Employment Information
Section 2
List information about the
Employment From (mm/dd/yyyy)
Employment To (mm/dd/yyyy)
Employer
employer you worked for at
Type of Credit
Service Prior to Membership
CETA
Fellowship
the time of your service.
c
c
c
Layoff
Prior Service
Optional Member Service
c
c
c
Employment From (mm/dd/yyyy)
Employment To (mm/dd/yyyy)
Employer
Type of Credit
Service Prior to Membership
CETA
Fellowship
c
c
c
Layoff
Prior Service
Optional Member Service
c
c
c
Member Certification
Section 3
I hereby certify under penalty of perjury the above information is true and correct to the best of my knowledge.
Complete the Member
I understand I must meet the requirements under California law. I have reviewed the publication A Guide to Your
Certification section and
CalPERS Service Credit Purchase Options (PUB 12) and I meet all the requirements outlined in the publication.
forward this form to the
I understand it is my responsibility to ensure this form is received by CalPERS. I further understand any balance
appropriate employer
resulting from an election must be paid in full by my retirement date, or my retirement benefit will be reduced by
for completion of the
the actuarial equivalent of the remaining balance.
Employer Certification.
Member Signature
Date (mm/dd/yyyy)
PERS-MSD-372 (8/20)
Page 1 of 2
Put your name and Social
Security number or CalPERS ID
Your Name
Social Security Number or CalPERS ID
at the top of every page
Employer Certification
Section 4
For Service Prior to Membership, Comprehensive Employment & Training Act (CETA), Fellowship, Prior Service,
or Optional Member Service, upload and complete the Employment Certification electronically.
For Layoff only, complete Sections 4 and 5 and return to the member.
Reminder: If the employee has indicated a retirement date in Section 1, it is imperative that CalPERS receive
this completed Employer Certification section promptly. Delays in receiving this information from your agency
could affect the employee’s ability to make their election prior to retirement.
Member Layoff History (To be completed by the employer at the time of the member’s layoff.)
For layoff, list the
dates the member
was laid off work.
Date From (mm/dd/yyyy)
Date To (mm/dd/yyyy)
Statement and Signature of Personnel or Payroll Officer
Section 5
Required: By signing, I certify the following:
1.
The information provided in Section 4 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 2 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 2 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-372 (8/20)
Page 2 of 2
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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