Form PERS-MSD-369 "Request for Service Credit Cost Information - Military Service" - California

This version of the form is not currently in use and is provided for reference only.
Download this version of Form PERS-MSD-369 for the current year.

What Is Form PERS-MSD-369?

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 PERS-MSD-369 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 PERS-MSD-369 "Request for Service Credit Cost Information - Military Service" - California

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Request for Service Credit Cost Information —
Military 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
(
)
Former Name (if applicable)
Daytime Phone
Mailing Address
City
State
ZIP Code
Current Employer
What date do you plan to retire?
Retirement Date (mm/dd/yyyy)
Were you employed by a CalPERS-covered employer and granted a leave of absence to enter the military?
No
Yes
c
c
If you were employed by a
Employer
CalPERS-covered employer
Are you a member of a public retirement system in California other than CalPERS?
No
Yes
c
c
and were granted a leave
of absence to enter the
Name of System
military, check the Yes
Is the military service being requested already credited in another retirement system?
No
Yes
c
c
box and indicate your
employer’s name.
Name of System
Military Active Duty Service Dates
Section 2
(attach certification)
List your active duty
Armed Forces Branch
Enlistment Date (mm/dd/yyyy)
Discharge Date (mm/dd/yyyy)
military service dates from
your Military Certification.
Armed Forces Branch
Enlistment Date (mm/dd/yyyy)
Discharge Date (mm/dd/yyyy)
Armed Forces Branch
Enlistment Date (mm/dd/yyyy)
Discharge Date (mm/dd/yyyy)
Requested number of years to purchase: ____________
Maximum years allowable
c
Member Certification
Section 3
I hereby certify that the above information is true and correct.
Sign and date the
request form. Make a copy
for your records.
Member Signature
Date (mm/dd/yyyy)
Attach a copy of your
military discharge or leave
of absence documents
(i.e., DD-214). Also attach
a copy of your cost
estimate from the Service
Credit Cost Estimator at
www.calpers.ca.gov/
servicecreditestimator.
Mail to:
CalPERS Member Account Management Division
P.O. Box 4000, Sacramento, California 95812-4000
PERS-MSD-369 (10/17)
Page 1 of 1
Request for Service Credit Cost Information —
Military 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
(
)
Former Name (if applicable)
Daytime Phone
Mailing Address
City
State
ZIP Code
Current Employer
What date do you plan to retire?
Retirement Date (mm/dd/yyyy)
Were you employed by a CalPERS-covered employer and granted a leave of absence to enter the military?
No
Yes
c
c
If you were employed by a
Employer
CalPERS-covered employer
Are you a member of a public retirement system in California other than CalPERS?
No
Yes
c
c
and were granted a leave
of absence to enter the
Name of System
military, check the Yes
Is the military service being requested already credited in another retirement system?
No
Yes
c
c
box and indicate your
employer’s name.
Name of System
Military Active Duty Service Dates
Section 2
(attach certification)
List your active duty
Armed Forces Branch
Enlistment Date (mm/dd/yyyy)
Discharge Date (mm/dd/yyyy)
military service dates from
your Military Certification.
Armed Forces Branch
Enlistment Date (mm/dd/yyyy)
Discharge Date (mm/dd/yyyy)
Armed Forces Branch
Enlistment Date (mm/dd/yyyy)
Discharge Date (mm/dd/yyyy)
Requested number of years to purchase: ____________
Maximum years allowable
c
Member Certification
Section 3
I hereby certify that the above information is true and correct.
Sign and date the
request form. Make a copy
for your records.
Member Signature
Date (mm/dd/yyyy)
Attach a copy of your
military discharge or leave
of absence documents
(i.e., DD-214). Also attach
a copy of your cost
estimate from the Service
Credit Cost Estimator at
www.calpers.ca.gov/
servicecreditestimator.
Mail to:
CalPERS Member Account Management Division
P.O. Box 4000, Sacramento, California 95812-4000
PERS-MSD-369 (10/17)
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
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