"Public Agency Applicant Questionnaire" - California

Public Agency Applicant Questionnaire is a legal document that was released by the California Public Employees' Retirement System - a government authority operating within California.

Form Details:

  • Released on January 1, 2018;
  • The latest edition currently provided by the California Public Employees' Retirement System;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the California Public Employees' Retirement System.

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California Public Employees’ Retirement System
Financial Office | Pension Contract Management Services &
Prefunding Programs
P.O. Box 942709
Sacramento, CA 94229-2709
TTY: (877) 249-7442
888 CalPERS (or 888-225-7377) phone • (916) 795-4673 fax
www.calpers.ca.gov
Public Agency Applicant Questionnaire
Thank you for your interest in the California Public Employees’ Retirement System (CalPERS)
benefit programs. Please complete this Public Agency Applicant Questionnaire (Application) as
thoroughly as possible and provide supporting documentation for all responses. Your
application cannot be reviewed until all requested information has been provided. We ask that
you provide clear and complete answers to avoid delays in the review of your Application.
Once you submit your completed Public Agency Applicant Questionnaire, a CalPERS analyst
will be assigned to your case and will be available to assist you in the contracting process.
Keep in mind this Application is only the first step in the application process and we may
require additional information or supporting documentation from you as part of the
application process. CalPERS staff will contact you with more specific details on the
contracting process after we receive your completed Application and be available to you
throughout the process.
Before fully reviewing your application information, we cannot guarantee you will be eligible
to contract with CalPERS for participation in the CalPERS benefit plans (CalPERS Plans). This
Application is not an offer to contract. Therefore, do not withhold CalPERS retirement
contributions from any of your employees in anticipation of eligibility to participate in the
CalPERS Plans, nor should you report your employees under any other agency currently
participating in the CalPERS Plans.
Agency Contact Information:
Official Agency:
Mailing Address:
Street Address:
City, State, Zip:
County:
Authorized Agency Representative:
Name:
Title:
Telephone:
E-mail:
Rev. Date January 2018
Page 1 of 8
California Public Employees’ Retirement System
Financial Office | Pension Contract Management Services &
Prefunding Programs
P.O. Box 942709
Sacramento, CA 94229-2709
TTY: (877) 249-7442
888 CalPERS (or 888-225-7377) phone • (916) 795-4673 fax
www.calpers.ca.gov
Public Agency Applicant Questionnaire
Thank you for your interest in the California Public Employees’ Retirement System (CalPERS)
benefit programs. Please complete this Public Agency Applicant Questionnaire (Application) as
thoroughly as possible and provide supporting documentation for all responses. Your
application cannot be reviewed until all requested information has been provided. We ask that
you provide clear and complete answers to avoid delays in the review of your Application.
Once you submit your completed Public Agency Applicant Questionnaire, a CalPERS analyst
will be assigned to your case and will be available to assist you in the contracting process.
Keep in mind this Application is only the first step in the application process and we may
require additional information or supporting documentation from you as part of the
application process. CalPERS staff will contact you with more specific details on the
contracting process after we receive your completed Application and be available to you
throughout the process.
Before fully reviewing your application information, we cannot guarantee you will be eligible
to contract with CalPERS for participation in the CalPERS benefit plans (CalPERS Plans). This
Application is not an offer to contract. Therefore, do not withhold CalPERS retirement
contributions from any of your employees in anticipation of eligibility to participate in the
CalPERS Plans, nor should you report your employees under any other agency currently
participating in the CalPERS Plans.
Agency Contact Information:
Official Agency:
Mailing Address:
Street Address:
City, State, Zip:
County:
Authorized Agency Representative:
Name:
Title:
Telephone:
E-mail:
Rev. Date January 2018
Page 1 of 8
Please provide complete copies of the Employer’s JPA agreement, Articles of Incorporation, Bylaws,
any amendments, and any filings with the Secretary of State, as applicable. Please feel free to provide
your answers on additional pages, if necessary.
Public Agency Applicant Questions:
1. Is the entity a City or County?
No.
Yes. If yes, you do not need to answer any additional questions. Please proceed to signing the
attached “Employer Certification” on page 8 of this Application along with your supporting
documentation (e.g. charter, formation documents).
2. What type of entity is the Employer?
Joint Powers Authority (JPA)
Non-Profit Corporation, or
Other: If other, please describe:
3. Please list:
• the current members of the Employer’s governing board or body
• the date each individual was elected or appointed, and
• The individual’s current job/title.
Current Members of
Date Each Individual was
Current Job/Title
Employer’s Governing
Elected or Appointed
Board or Body
4. Please indicate whether the members of the Employer’s governing board or body are
Elected or
Appointed? If appointed, who has the power to appoint members of the
Employer’s governing board or body?
Rev. Date January 2018
Page 2 of 8
5. Does any person or entity have the power to remove members of the Employer’s
Governing board or body?
No.
Yes. If yes, please describe in detail and include references to Bylaws, contracts or
agreements, or other governing documents:
6. Please list other individuals or entities that have control or voting powers or that have
ownership or other interests in the Employer:
• describe the powers or interests in detail
• include references to Bylaws, contracts or agreements, or other governing
documents.
Individuals/Entities
Powers/Interests
References
7. Please list:
• any entity(ies) or organization(s) that is/are related to or affiliated with the
Employer
• describe the relationship between the Employer and such entity(ies) or
organization(s) in detail.
• include references to Bylaws, contracts or agreements, or other governing
documents.
Affiliated Entities /
Relationship
References
Organizations
Rev. Date January 2018
Page 3 of 8
8. Does the State (or a City or County or other political subdivision of the State) have fiscal
responsibility for the general debts and other liabilities of the Employer?
No.
Yes. If yes, please describe in detail and include references to Bylaws, contracts or
agreements, or other governing documents:
9. Please describe in detail:
• All governmental or quasi-governmental powers exercised and functions
performed by the Employer. Please make sovereign powers explicit (e.g.
police, taxation, eminent domain)
• Include references to statutes, Bylaws, contracts or agreements, or other
governing documents relating to the Employer’s powers and functions.
Governmental Functions
References Related to
Sovereign Powers
Performed
Powers/Functions
10. Was the Employer created by a specific enabling statute that prescribes the purposes,
powers, duties, or obligations of the Employer?
No.
Yes. If yes, please describe in detail:
11. Does the State (or a City or County or other political subdivision of the State) exercise control
over the Employer’s operations or property or have the right to exercise such control?
No.
Yes. If yes, please describe in detail and include references to Bylaws,
contracts or agreements, or other governing documents:
Rev. Date January 2018
Page 4 of 8
12. Are the Employer’s employees treated the same as State, City or County employees for
purposes other than providing employee benefits? Please describe in detail.
Examples:
• Are the Employer’s hiring practices subject to a competitive examination process? If so,
please provide an example.
• Are employees subject to civil service law and rules
• Are employees subject to collective bargaining laws (e.g. Meyers-Milias-Brown Act)
• Are the Employer’s employees’ salaries and benefits subject to collective bargaining?
If so, please provide the name of employee organization group(s) who represent the
Employer’s employees in collective bargaining.
• What grievance procedures and administrative appeals rights are made available by the
Employer?
No.
Yes. If yes, please describe in detail:
13. Please provide a detailed description of all sources of revenue or funding, including a
description of any non-public sources, received or expected to be received by the
Employer to establish or operate the Employer.
• Please include the percentages of total funding coming from all sources.
Percentage of Total
Sources of Revenue/Funding
Funding (all)
Rev. Date January 2018
Page 5 of 8
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