Form PERS01M0396 DMC "Election of Optional Membership - California National Guard Member" - California

What Is Form PERS01M0396 DMC?

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 October 1, 2017;
  • 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 printable version of Form PERS01M0396 DMC by clicking the link below or browse more documents and templates provided by the California Public Employees' Retirement System.

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Forms
Election of Optional Membership —
California National Guard Member
888 CalPERS (or 888-225-7377) TTY: (877) 249-7442
Election of Optional California National Guard Membership
Section 1
You may submit this election of optional National Guard membership at any time while in active service
Important
with the California National Guard. Once elected, the membership remains in effect for all future service
California National Guard
members who elect
in the California National Guard. Below are important steps and considerations:
membership in CalPERS
To become a “National Guard member” of CalPERS (pursuant to Government Code section 20326),
must pay both member
officers, warrant officers, and enlisted personnel of the California National Guard must:
and employer retirement
- Complete this election form.
contributions.
- Once completed, send this election form to the Military Department for certification and
You must elect optional
filing with the CalPERS Board of Administration.
California National Guard
As a California National Guard member, you will contribute to the retirement fund in accordance
membership in CalPERS to
with Government Code section 20772.5, as described below:
purchase your prior National
Guard service credit.
-
paid at the employee rate applicable
California National Guard Member Contributions:
to state miscellaneous members; and
If you are already making
-
Employer Contributions (paid by California National Guard member):
paid at the employer
retirement contributions
contribution rate, which is adjusted on an annual basis, pursuant to section 20814.
to CalPERS in another
concurrent position, please
As a California National Guard member, you may, on a
basis, cancel your election
prospective
call us at 888 CalPERS
of National Guard membership by filing a completed Cancellation of Election of Optional
(or 888-225-7377) before
Membership—California National Guard Member form with the Military Department for
you submit your election.
submission to the CalPERS Board (Government Code section 20327).
This prospective
cancellation may only be made once.
Purchasing Prior National Guard Service Credit
Upon electing optional California National Guard membership in CalPERS, you may elect (prior to
retirement) to purchase service credit for your eligible prior service in the California National Guard,
unless the service was terminated by a discharge under other than honorable conditions.
To request this past California National Guard service, complete the Request for Service Credit Cost
Information —California National Guard Military form, which is available at
www.calpers.ca.gov
.
PERS01M0396 DMC (10/17)
Page 1 of 2
Forms
Election of Optional Membership —
California National Guard Member
888 CalPERS (or 888-225-7377) TTY: (877) 249-7442
Election of Optional California National Guard Membership
Section 1
You may submit this election of optional National Guard membership at any time while in active service
Important
with the California National Guard. Once elected, the membership remains in effect for all future service
California National Guard
members who elect
in the California National Guard. Below are important steps and considerations:
membership in CalPERS
To become a “National Guard member” of CalPERS (pursuant to Government Code section 20326),
must pay both member
officers, warrant officers, and enlisted personnel of the California National Guard must:
and employer retirement
- Complete this election form.
contributions.
- Once completed, send this election form to the Military Department for certification and
You must elect optional
filing with the CalPERS Board of Administration.
California National Guard
As a California National Guard member, you will contribute to the retirement fund in accordance
membership in CalPERS to
with Government Code section 20772.5, as described below:
purchase your prior National
Guard service credit.
-
paid at the employee rate applicable
California National Guard Member Contributions:
to state miscellaneous members; and
If you are already making
-
Employer Contributions (paid by California National Guard member):
paid at the employer
retirement contributions
contribution rate, which is adjusted on an annual basis, pursuant to section 20814.
to CalPERS in another
concurrent position, please
As a California National Guard member, you may, on a
basis, cancel your election
prospective
call us at 888 CalPERS
of National Guard membership by filing a completed Cancellation of Election of Optional
(or 888-225-7377) before
Membership—California National Guard Member form with the Military Department for
you submit your election.
submission to the CalPERS Board (Government Code section 20327).
This prospective
cancellation may only be made once.
Purchasing Prior National Guard Service Credit
Upon electing optional California National Guard membership in CalPERS, you may elect (prior to
retirement) to purchase service credit for your eligible prior service in the California National Guard,
unless the service was terminated by a discharge under other than honorable conditions.
To request this past California National Guard service, complete the Request for Service Credit Cost
Information —California National Guard Military form, which is available at
www.calpers.ca.gov
.
PERS01M0396 DMC (10/17)
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
Applicant Signature and Certification
Section 2
I am a “National Guard member” as defined in Section 1. In accordance with the provisions of Government
Please review Section 1
Code section 20326,
I elect to become a National Guard member of CalPERS.
I request that this election
carefully before signing.
be filed with the Board of Administration of the California Public Employees’ Retirement System (CalPERS)
as my election to become a member.
I understand this election is irrevocable as long as I remain in
employment as a member; however, my obligation to make future membership contributions may be
canceled one time only, as provided in Government Code section 20327.
Please indicate your current CalPERS membership status:
I am currently an active CalPERS member employed with
.
c
I am not currently an active CalPERS member.
c
Name of Applicant (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
(
)
(
)
Birth Date (mm/dd/yyyy)
Daytime Phone
Evening Phone
Address
City
State
ZIP Code
Signature of Applicant
Date (mm/dd/yyyy)
Important:
Please submit this form to the Military Department, not CalPERS.
The Military Department will complete Section 3.
Mail to:
State Personnel Programs (SB 14 Team)
Box 27, 9800 Goethe Road, Sacramento, CA 95826-9101
Military Department Signature and Certification
Section 3
This section to be
Please complete this section and submit entire form to CalPERS.
completed by the
Please certify California National Guard employment status:
Military Department.
Active in the California National Guard
c
Part Time
Full Time
c
c
Officer
c
Warrant Officer
c
Enlisted
c
I hereby certify that this individual is currently active in the California National Guard as an officer,
warrant officer, or enlisted personnel.
Military Department Representative (First Name, Middle Initial, Last Name)
(
)
Title
Daytime Phone
Signature of Representative
Date (mm/dd/yyyy)
Mail to:
CalPERS Employer Account Management Division
P.O. Box 942709, Sacramento, California 95812-2709
PERS01M0396 DMC (10/17)
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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