Form 0697 "Report of Separation for Death - Request for Payroll Information" - California

What Is Form 0697?

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:

  • 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 0697 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 0697 "Report of Separation for Death - Request for Payroll Information" - California

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P.O. Box 942715 Sacramento, CA 94229-2715
888 CalPERS (or 888-225-7377) | Fax: (800) 959-6545
w w w.calpers.ca.gov
California Public Em ployees' Retirem ent System
Instructions for Completing the Report of Separation for Death
Request for Payroll Information
We have been notified that this member has passed away. In order for us to be able to pay survivor
benefits we require completion of the attached form. Your cooperation in immediately providing the
following information is an important part of ensuring the accurate and prompt payment of death benefits.
PART I. EFFECTIVE DATES REGARDING SEPARATION
Separation Date: Provide the last day that the member was considered an employee of your
organization.
Last Day on Pay Status: Provide the date that the member was last on pay status with your
organization. This would be the last day the member was subject to CalPERS contributions, whether
they were deducted from their earnings or not. Please explain any difference between date of separation
and last day on pay status, or, if member was on leave of absence, please provide the dates of absence.
Time Base: Check mark the correct time base for the member.
Required Hours: If part-time, also indicate required hours. Required hours are needed for the entire
period of employment.
Reason for Separation: Please check mark the reason member separated from employment. If other,
please provide a detailed explanation.
PART II. UNUSED SICK AND EDUCATIONAL LEAVE AT TIME OF SEPARATION
Please enter the total number of days or hours of unused sick leave and educational leave credits (G.C.
Section 20963.1) the employee had at the time of separation and check the box identifying hours or
days.
PART III. HEALTH AND DENTAL INSURANCE
To be completed only by State, Local, and School agencies which contract for health and/or dental
coverage under the Public Employees’ Hospital and Medical Care Act. Please attach copies of current
health and dental enrollment forms. Failure to provide this information may result in lapse of coverage
for eligible annuitants. Coverage Group code will need to be provided for Local and Sc hool agency
employees ONLY.
PART IV. CERTIFICATION OF EMPLOYER
Certify that the provided information is accurate and complete. Please include your direct telephone
number and extension.
my|CalPERS 0697
Page 1 of 2
P.O. Box 942715 Sacramento, CA 94229-2715
888 CalPERS (or 888-225-7377) | Fax: (800) 959-6545
w w w.calpers.ca.gov
California Public Em ployees' Retirem ent System
Instructions for Completing the Report of Separation for Death
Request for Payroll Information
We have been notified that this member has passed away. In order for us to be able to pay survivor
benefits we require completion of the attached form. Your cooperation in immediately providing the
following information is an important part of ensuring the accurate and prompt payment of death benefits.
PART I. EFFECTIVE DATES REGARDING SEPARATION
Separation Date: Provide the last day that the member was considered an employee of your
organization.
Last Day on Pay Status: Provide the date that the member was last on pay status with your
organization. This would be the last day the member was subject to CalPERS contributions, whether
they were deducted from their earnings or not. Please explain any difference between date of separation
and last day on pay status, or, if member was on leave of absence, please provide the dates of absence.
Time Base: Check mark the correct time base for the member.
Required Hours: If part-time, also indicate required hours. Required hours are needed for the entire
period of employment.
Reason for Separation: Please check mark the reason member separated from employment. If other,
please provide a detailed explanation.
PART II. UNUSED SICK AND EDUCATIONAL LEAVE AT TIME OF SEPARATION
Please enter the total number of days or hours of unused sick leave and educational leave credits (G.C.
Section 20963.1) the employee had at the time of separation and check the box identifying hours or
days.
PART III. HEALTH AND DENTAL INSURANCE
To be completed only by State, Local, and School agencies which contract for health and/or dental
coverage under the Public Employees’ Hospital and Medical Care Act. Please attach copies of current
health and dental enrollment forms. Failure to provide this information may result in lapse of coverage
for eligible annuitants. Coverage Group code will need to be provided for Local and Sc hool agency
employees ONLY.
PART IV. CERTIFICATION OF EMPLOYER
Certify that the provided information is accurate and complete. Please include your direct telephone
number and extension.
my|CalPERS 0697
Page 1 of 2
P.O. Box 942715 Sacramento, CA 94229-2715
888 CalPERS (or 888-225-7377) | Fax: (800) 959-6545
w w w.calpers.ca.gov
California Public Em ployees' Retirem ent System
PLEASE COMPLETE AND FAX TO (916) 795-3988 AS SOON AS POSSIBLE
REPORT OF SEPARATION FOR DEATH – REQUEST FOR PAYROLL INFORMATION
Business Partner CID:
Business Partner:
Member Name:
Date Of Death:
SSN:xxx-xx-
CID:
PART I. EFFECTIV E DATES REGARDING SEPARATION
:
Separation Date:
Last Day on Pay Status:
Reason for Separation
Death
Illness
Contract/Assignment Ended
(Note: The last day the
(Note: This date cannot be after
Other (please explain):
member was considered
the DOD or Separation date)
an employee)
Tim e Base:
Required Hours for entire m embership period:
(For part-tim e m embers, only)
Fulltime
Part-time
Indeterminate
Intermittent
Example: 11/10/2008 – 2/14/2012- 6hrs/day
Substitute
Seasonal
Worked as needed
From/To:
Other:
# of hours:
From/To:
# of hours:
PART II. UNUSED SICK AND EDUCATIONAL LEAVE AT TIME OF SEPARATION
TOTAL UNUSED SICK LEAVE:
DAYS
HOURS
BALANCE OF EDUCA TIONAL LEAVE CREDITS:
DAYS
HOURS
PART III. HEALTH AND DENTAL INSURANCE
Coverage Group (If
Type of Coverage
Plan Name
Name(s) of Covered Dependents
Applicable)
HEALTH INSURANCE
DENTAL INSURANCE
PART IV. CERTIFICATION OF EMPLOYER
Printed Name
Title
Direct Telephone Number and Extension
Signature of Payroll Officer
Date
my|CalPERS 0697
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