"California Employers' Retiree Benefit Trust Disbursement Request Form" - California

California Employers' Retiree Benefit Trust Disbursement Request Form is a legal document that was released by the California Public Employees' Retirement System - a government authority operating within California.

Form Details:

  • Released on April 24, 2017;
  • The latest edition currently provided by the California Public Employees' Retirement System;
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California Employers’ Retiree Benefit Trust
Disbursement Request
To request a disbursement from your California Employers’ Retiree Benefit Trust (CERBT)
employer account, please complete this form (see page 3 for instructions):
Employer Name
CERBT Account #
Street Address 1
Street Address 2
City/State/ZIP
OPEB Provider
OPEB Cost Paid
Payment Period
Total CERBT
XXXXXXXXXXXXXXXX
Disbursement Requested
Employer understands disbursements from the Prefunding Plan are governed by the terms
of the Agreement and Election to Prefund Other Post-Employment Benefits (Agreement).
Authority to request disbursements has been delegated by the governing board of the
agency to the undersigned.
CERBT Disbursement Request
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Rev 04/24/2017
S
California Employers’ Retiree Benefit Trust
Disbursement Request
To request a disbursement from your California Employers’ Retiree Benefit Trust (CERBT)
employer account, please complete this form (see page 3 for instructions):
Employer Name
CERBT Account #
Street Address 1
Street Address 2
City/State/ZIP
OPEB Provider
OPEB Cost Paid
Payment Period
Total CERBT
XXXXXXXXXXXXXXXX
Disbursement Requested
Employer understands disbursements from the Prefunding Plan are governed by the terms
of the Agreement and Election to Prefund Other Post-Employment Benefits (Agreement).
Authority to request disbursements has been delegated by the governing board of the
agency to the undersigned.
CERBT Disbursement Request
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Rev 04/24/2017
California Employers’ Retiree Benefit Trust
Disbursement Request
The undersigned is/are authorized to request disbursements, under the terms of the
Agreement from the CERBT. The undersigned certifies the payment information provided
above is accurate, and reimbursement requested is for other post-employment benefit
costs paid by the employer. For amounts of ten thousand dollars ($10,000) or more,
signatures of two authorized employer representatives are required. Reimbursement
for expenses related to periods prior to July 1 can only be made if a properly executed
disbursement request is received by CalPERS on or before July 31. After July 31,
reimbursements can only be made for current fiscal year expenses (incurred on or after
July 1) regardless of the employer’s fiscal year end date.
Authorized Employer Representative
Title
Telephone Number
Printed Name
Signature
Email address
Date
Authorized Employer Representative
Title
Telephone Number
Printed Name
Signature
Email address
Date
Mail Completed CERBT Disbursement Request to the following address:
CalPERS
CERBT/OPEB
PO Box 1494
Sacramento, CA 95812-1494
In addition, please email an electronic copy of this form to
CERBT4U@calpers.ca.gov
to ensure timely processing of your disbursement.
For CalPERS use only
Confirmed Authorized Employer
Received by CERBT:
Representative:
OPEB retiree cost amounts confirmed
CERBT Contract Eff. Date:
as reasonable compared to projections:
CalPERS Approved By:
Approval Date:
FINO:
FINO Approved by:
FINO Approval Date:
Claim Schedule number:
Claim Schedule Date:
CERBT Disbursement Request
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Rev 04/24/2017
California Employers’ Retiree Benefit Trust
Disbursement Request
Instructions to complete this form
1. Enter the name of the employer and its business address.
2. Report the name of the payee (service provider or other) to which payments for
other post-employment benefits (OPEB) were made by the employer. Record the
total OPEB payments made to the OPEB Provider (see example below). Trust
disbursements can be made only for OPEB costs in accordance with the terms of
the Agreement and Election to Pre-fund Other Post-Employment Benefits Through
CalPERS (Agreement). The payment period cannot pre-date the effective date of
the Agreement.
OPEB Provider
OPEB Cost Paid
Payment Period
Blue Shield
$151,368
July 2011 - June 2012
Delta Dental
$27,842
Jan 2012 - June 2012
Total CERBT
Disbursement Request
$179,210
XXXXXXXXXXXXXXXX
3. The form must be signed by incumbents of positions authorized to request CERBT
disbursements. These positions are named in the Delegation to Request
Disbursements on file with CalPERS. For amounts of ten thousand ($10,000) or
more, two signatures are required.
4. Disbursements will be made payable to the employer and sent to the employer’s
business address on record with CalPERS, attention of an authorized employer
representative who signed this Disbursement Request. Disbursement requests that
satisfy the Agreement and are received on or after the 1st of the month will be
processed the following month.
5. Disbursements related to the prior fiscal year (July through June) must be
presented to CalPERS by July 31 of each year and will be accrued if the
disbursement request is received before July 31. After July 31, no reimbursements
can be made for periods before July of the current fiscal year.
CERBT Disbursement Request
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California Employers’ Retiree Benefit Trust
Disbursement Request
6. Disbursements for Implicit Subsidy amounts must be supported by an actuarial
valuation (or AMM report) or addendum certified by your actuary showing the
calculated implied subsidy amount for the period.
CERBT Disbursement Request
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