Form PERS-MSD-373 "Request for Service Credit Cost Information - Peace Corps, Americorps Vista, or Americorps" - California

What Is Form PERS-MSD-373?

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 PERS-MSD-373 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-373 "Request for Service Credit Cost Information - Peace Corps, Americorps Vista, or Americorps" - California

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Request for Service Credit Cost Information —
Peace Corps, AmeriCorps VISTA, or AmeriCorps
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
Former Name (if applicable)
Daytime Phone
purchase service credit
must be received
Mailing Address
by CalPERS at least
one day prior to your
City
State
ZIP Code
retirement date.
Current Employer
What date do you plan to retire?
Retirement Date (mm/dd/yyyy)
Are you a member of a public retirement system in California other than CalPERS?
No
Yes
c
c
Name of System
Peace Corps, AmeriCorps VISTA, or AmeriCorps Service Dates
Section 2
(attach certification)
List your Peace Corps,
AmeriCorps VISTA, or
Indicate Peace Corps, AmeriCorps VISTA, or AmeriCorps
AmeriCorps service dates.
Beginning Date of Service (mm/dd/yyyy)
Ending Date of Service (mm/dd/yyyy)
Member Certification
Section 3
Sign and date the
I hereby certify that the above information is true and correct.
request form. Make a
copy for your records.
Member Signature
Date (mm/dd/yyyy)
Attach a copy of your Peace
Corps, AmeriCorps VISTA, or
AmeriCorps certification letter
and a copy of your service
credit purchase cost estimate.
Obtain a 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-373 (10/17)
Page 1 of 1
Request for Service Credit Cost Information —
Peace Corps, AmeriCorps VISTA, or AmeriCorps
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
Former Name (if applicable)
Daytime Phone
purchase service credit
must be received
Mailing Address
by CalPERS at least
one day prior to your
City
State
ZIP Code
retirement date.
Current Employer
What date do you plan to retire?
Retirement Date (mm/dd/yyyy)
Are you a member of a public retirement system in California other than CalPERS?
No
Yes
c
c
Name of System
Peace Corps, AmeriCorps VISTA, or AmeriCorps Service Dates
Section 2
(attach certification)
List your Peace Corps,
AmeriCorps VISTA, or
Indicate Peace Corps, AmeriCorps VISTA, or AmeriCorps
AmeriCorps service dates.
Beginning Date of Service (mm/dd/yyyy)
Ending Date of Service (mm/dd/yyyy)
Member Certification
Section 3
Sign and date the
I hereby certify that the above information is true and correct.
request form. Make a
copy for your records.
Member Signature
Date (mm/dd/yyyy)
Attach a copy of your Peace
Corps, AmeriCorps VISTA, or
AmeriCorps certification letter
and a copy of your service
credit purchase cost estimate.
Obtain a 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-373 (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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