Form PERS-BSD-194 Report of Separation and Advance Payroll Information - California

Form PERS-BSD-194 is a California Public Employees' Retirement System form also known as the "Report Of Separation And Advance Payroll Information". The latest edition of the form was released in March 1, 2012 and is available for digital filing.

Download an up-to-date Form PERS-BSD-194 in PDF-format down below or look it up on the California Public Employees' Retirement System Forms website.

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Report of Separation and Advance
Payroll Information
888 CalPERS (or 888-225-7377)
TTY: (877) 249-7442
Employer: Please complete this form as soon as possible and return to CalPERS.
Employing Agency and Member Information
Section 1
Your cooperation in
Name of Employing Agency
immediately providing an
This member has applied for disability retirement.
advance estimate of the
requested information
Name of Member (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
is critical for us to make
accurate payment at the
Requested Retirement Date (mm/dd/yyyy)
earliest possible date.
Effective Separation or Termination Dates
Section 2
Last day on pay status
Last Day on Pay Status (mm/dd/yyyy)
Separation Date (mm/dd/yyyy)
Termination Date (mm/dd/yyyy)
will be upon expiration
of accrued sick leave or
Leave of Absence With Compensation
compensated time off.
Beginning Date (mm/dd/yyyy)
Ending Date (mm/dd/yyyy)
Type of Compensation
A termination date is
the date an employee is
Explain the difference between the date of separation and last day on pay status, if any.
terminated from CalPERS-
covered employment
“for cause”; use only
when applicable.
Unused Sick Leave at Time of Separation
Section 3
Accumulated hours must be converted to
using the appropriate conversion factor applicable to each
days
employee’s individual classification or position. Calculate to three decimal places.
Balance of unused sick leave hours at time of separation:
÷ 8 =
Hours
Days
Certification of Employer
Section 4
The above information is based on payroll information currently available.
Signature of Payroll Officer
Title
(
)
Date (mm/dd/yyyy)
Phone Number
Mail to:
CalPERS Benefit Services Division
P.O. Box 942711, Sacramento, California 94229-2711
PERS-BSD-194 (3/12)
Page 1 of 1
Report of Separation and Advance
Payroll Information
888 CalPERS (or 888-225-7377)
TTY: (877) 249-7442
Employer: Please complete this form as soon as possible and return to CalPERS.
Employing Agency and Member Information
Section 1
Your cooperation in
Name of Employing Agency
immediately providing an
This member has applied for disability retirement.
advance estimate of the
requested information
Name of Member (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
is critical for us to make
accurate payment at the
Requested Retirement Date (mm/dd/yyyy)
earliest possible date.
Effective Separation or Termination Dates
Section 2
Last day on pay status
Last Day on Pay Status (mm/dd/yyyy)
Separation Date (mm/dd/yyyy)
Termination Date (mm/dd/yyyy)
will be upon expiration
of accrued sick leave or
Leave of Absence With Compensation
compensated time off.
Beginning Date (mm/dd/yyyy)
Ending Date (mm/dd/yyyy)
Type of Compensation
A termination date is
the date an employee is
Explain the difference between the date of separation and last day on pay status, if any.
terminated from CalPERS-
covered employment
“for cause”; use only
when applicable.
Unused Sick Leave at Time of Separation
Section 3
Accumulated hours must be converted to
using the appropriate conversion factor applicable to each
days
employee’s individual classification or position. Calculate to three decimal places.
Balance of unused sick leave hours at time of separation:
÷ 8 =
Hours
Days
Certification of Employer
Section 4
The above information is based on payroll information currently available.
Signature of Payroll Officer
Title
(
)
Date (mm/dd/yyyy)
Phone Number
Mail to:
CalPERS Benefit Services Division
P.O. Box 942711, Sacramento, California 94229-2711
PERS-BSD-194 (3/12)
Page 1 of 1
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

Download Form PERS-BSD-194 Report of Separation and Advance Payroll Information - California

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