Form 01M0352DMC "Request for Service Credit Cost Information - Alternate Retirement Program Service" - California

What Is Form 01M0352DMC?

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;

Download a printable version of Form 01M0352DMC 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 01M0352DMC "Request for Service Credit Cost Information - Alternate Retirement Program Service" - California

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Request for Service Credit Cost Information —
Alternate Retirement Program 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
Your valid election to
Member Mailing Address
purchase service credit
(
)
must be received
City
State
ZIP Code
Daytime Phone
by CalPERS at least
one day prior to your
What date do you plan to retire?
Retirement Date (mm/dd/yyyy)
retirement date.
Have you ever been a member of a public retirement system in California other than CalPERS?
No
Yes
c
c
If yes, which retirement system?
Employment Information
Section 2
List all periods of CalPERS-covered employment during your first two years of CalPERS membership.
Please include the month,
day, and year for all
dates as: mm/dd/yyyy.
Employer
From (mm/dd/yyyy)
To (mm/dd/yyyy)
Employer
From (mm/dd/yyyy)
To (mm/dd/yyyy)
Employer
From (mm/dd/yyyy)
To (mm/dd/yyyy)
Employer
From (mm/dd/yyyy)
To (mm/dd/yyyy)
Member Certification
Section 3
I hereby certify that the above information is true and correct to the best of my knowledge. I understand that this
Sign and date the form,
form does not execute the transfer of my Alternate Retirement Program funds to CalPERS during my three-month
make a copy for your
election period as defined in sections 20908(a) and 20908(b) of the Government Code. I also understand that it is
records, and mail the
my responsibility to ensure this form is received by CalPERS.
original to the address
shown below.
Member Signature
Date (mm/dd/yyyy)
Mail to:
CalPERS Member Account Management Division
P.O. Box 4000, Sacramento, California 95812-4000
PERS01M0352DMC (10/17)
Page 1 of 1
Request for Service Credit Cost Information —
Alternate Retirement Program 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
Your valid election to
Member Mailing Address
purchase service credit
(
)
must be received
City
State
ZIP Code
Daytime Phone
by CalPERS at least
one day prior to your
What date do you plan to retire?
Retirement Date (mm/dd/yyyy)
retirement date.
Have you ever been a member of a public retirement system in California other than CalPERS?
No
Yes
c
c
If yes, which retirement system?
Employment Information
Section 2
List all periods of CalPERS-covered employment during your first two years of CalPERS membership.
Please include the month,
day, and year for all
dates as: mm/dd/yyyy.
Employer
From (mm/dd/yyyy)
To (mm/dd/yyyy)
Employer
From (mm/dd/yyyy)
To (mm/dd/yyyy)
Employer
From (mm/dd/yyyy)
To (mm/dd/yyyy)
Employer
From (mm/dd/yyyy)
To (mm/dd/yyyy)
Member Certification
Section 3
I hereby certify that the above information is true and correct to the best of my knowledge. I understand that this
Sign and date the form,
form does not execute the transfer of my Alternate Retirement Program funds to CalPERS during my three-month
make a copy for your
election period as defined in sections 20908(a) and 20908(b) of the Government Code. I also understand that it is
records, and mail the
my responsibility to ensure this form is received by CalPERS.
original to the address
shown below.
Member Signature
Date (mm/dd/yyyy)
Mail to:
CalPERS Member Account Management Division
P.O. Box 4000, Sacramento, California 95812-4000
PERS01M0352DMC (10/17)
Page 1 of 1