Form PERS07M0044DMC "Request to Work While Receiving Disability / Industrial Disability Retirement Benefits" - California

What Is Form PERS07M0044DMC?

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 July 1, 2015;
  • 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 PERS07M0044DMC 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 PERS07M0044DMC "Request to Work While Receiving Disability / Industrial Disability Retirement Benefits" - California

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Request To Work While Receiving Disability /
Industrial Disability Retirement Benefits
888 CalPERS (or 888-225-7377)
TTY (877) 249-7442
You must complete this form in order to request approval to work for a CalPERS employer in any permanent
position while continuing your disability / industrial disability retirement benefits.
Member Certification
Section 1
Please clearly print the
Name of Member (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
requested information.
Address
A Physician’s Report
on Disability form
is not required.
City
State
ZIP Code
Country
(
)
(
)
Be sure to have your
Daytime Phone
Fax Number
E-Mail Address
employer fill out Section 2
I understand this is a formal request for permanent employment under Government Code Section
on the reverse side of
21232 and that my employment offer is contingent upon written approval from CalPERS.
I must advise
this form.
CalPERS of any changes to my salary or employment (for e.g. lateral transfer or promotion) and receive
approval before beginning any new permanent position. A consequence of unlawful employment may
Local safety disability
or industrial disability
result in mandatory reinstatement from retirement into the position I am currently working, retroactive
retirees must also submit
to my hire date.
the position duty statement
I also understand that the position I am applying for must be significantly different than the one from
and qualifying medical
which I retired. I am subject to an earnings limitation so that the total of the pension portion of my
documentation used at the
retirement allowance and employment earnings will not exceed the current (gross) salary of the position
time of their retirement.
from which I retired.
I have attached a position duty statement of the job and a completed Physical Requirements of Position/
Occupational Title form. I have also attached a current medical report completed and signed by a
physician specializing in the condition for which I retired on disability/industrial disability retirement.
The physician is a medical specialist who certifies that he/she has examined me, reviewed the attached
position duty statement and Physical Requirements of Position/Occupational Title form and indicates
whether or not I am able to perform all of the tasks without any restrictions or limitations.
Member Signature
Date (mm/dd/yyyy)
This form continues on the back.
PERS07M0044DMC (7/15)
Page 1 of 2
Request To Work While Receiving Disability /
Industrial Disability Retirement Benefits
888 CalPERS (or 888-225-7377)
TTY (877) 249-7442
You must complete this form in order to request approval to work for a CalPERS employer in any permanent
position while continuing your disability / industrial disability retirement benefits.
Member Certification
Section 1
Please clearly print the
Name of Member (First Name, Middle Initial, Last Name)
Social Security Number or CalPERS ID
requested information.
Address
A Physician’s Report
on Disability form
is not required.
City
State
ZIP Code
Country
(
)
(
)
Be sure to have your
Daytime Phone
Fax Number
E-Mail Address
employer fill out Section 2
I understand this is a formal request for permanent employment under Government Code Section
on the reverse side of
21232 and that my employment offer is contingent upon written approval from CalPERS.
I must advise
this form.
CalPERS of any changes to my salary or employment (for e.g. lateral transfer or promotion) and receive
approval before beginning any new permanent position. A consequence of unlawful employment may
Local safety disability
or industrial disability
result in mandatory reinstatement from retirement into the position I am currently working, retroactive
retirees must also submit
to my hire date.
the position duty statement
I also understand that the position I am applying for must be significantly different than the one from
and qualifying medical
which I retired. I am subject to an earnings limitation so that the total of the pension portion of my
documentation used at the
retirement allowance and employment earnings will not exceed the current (gross) salary of the position
time of their retirement.
from which I retired.
I have attached a position duty statement of the job and a completed Physical Requirements of Position/
Occupational Title form. I have also attached a current medical report completed and signed by a
physician specializing in the condition for which I retired on disability/industrial disability retirement.
The physician is a medical specialist who certifies that he/she has examined me, reviewed the attached
position duty statement and Physical Requirements of Position/Occupational Title form and indicates
whether or not I am able to perform all of the tasks without any restrictions or limitations.
Member Signature
Date (mm/dd/yyyy)
This form continues on the back.
PERS07M0044DMC (7/15)
Page 1 of 2
Put your name and Social
Security number or CalPERS ID
Your Name
Social Security Number or CalPERS ID
at the top of every page
Employer Certification
Section 2
It is the intent of:
to hire:
Permanent employment
Employer
CalPERS Member
or changes in employment
in the position of:
pursuant of Government Code Section 21232;
status (e.g., lateral transfer
Job Title
or promotion) that begins
and contingent upon written approval from CalPERS.
prior to written approval
from CalPERS may result in
mandatory reinstatement.
Employer Address (City, State, ZIP Code)
Daytime Phone
Fax Number
E-Mail Address
We understand that reinstatement of the retiree, due to unlawful employment, to any position within
our agency, may result in penalties and payment of contributions to CalPERS, retroactive to retiree’s
date of hire.
The salary range for this position is:
hourly/monthly.
Employer Signature
Date (mm/dd/yyyy)
Print Name of Authorized Personnel
Classification Title
Mail to:
CalPERS Benefit Services Division
P.O. Box 2796, Sacramento, California 95812-2796
PERS07M0044DMC (7/15)
Page 2 of 2
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
Page of 3