"School Applicant Questionnaire Form" - California

School Applicant Questionnaire Form is a legal document that was released by the California Public Employees' Retirement System - a government authority operating within California.

Form Details:

  • Released on January 1, 2018;
  • The latest edition currently provided by the California Public Employees' Retirement System;
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  • Fill out the form in our online filing application.

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California Public Employees’ Retirement System
Financial Office | Pension Contract Management Services &
Prefunding Programs
P.O. Box 942709
Sacramento, CA 94229-2709
TTY: (877) 249-7442
888 CalPERS (or 888-225-7377) phone • (916) 795-4673 fax
www.calpers.ca.gov
School Applicant Questionnaire
Thank you for your interest in the California Public Employees’ Retirement System (CalPERS)
benefit programs. Please complete this School Applicant Questionnaire (Application) as
thoroughly as possible and provide supporting documentation for all responses. Your
application cannot be reviewed until all requested information has been provided. We ask that
you provide clear and complete answers to avoid delays in the review of your Application.
Once you submit your completed School Applicant Questionnaire, a CalPERS analyst will be
assigned to your case and will be available to assist you in the contracting process.
Keep in mind this Application is only the first step in the application process and we may
require additional information or supporting documentation from you as part of the application
process. CalPERS staff will contact you with more specific details on the contracting process
after we receive your completed Application and be available to you throughout the process.
Before fully reviewing your application information, we cannot guarantee you will be eligible to
contract with CalPERS for participation in the CalPERS benefit plans (CalPERS Plans). This
Application is not an offer to contract. Therefore, do not withhold and report CalPERS
retirement contributions from any of your employees in anticipation of eligibility to participate
in the CalPERS Plans, nor should you report your employees under any other agency currently
participating in the CalPERS Plans.
Agency Contact Information:
Official Agency:
Mailing Address:
Street Address:
City, State, Zip:
County:
Authorized Agency Representative:
Name:
Title:
Telephone:
E-mail:
January 2018
Page 1 of 5
California Public Employees’ Retirement System
Financial Office | Pension Contract Management Services &
Prefunding Programs
P.O. Box 942709
Sacramento, CA 94229-2709
TTY: (877) 249-7442
888 CalPERS (or 888-225-7377) phone • (916) 795-4673 fax
www.calpers.ca.gov
School Applicant Questionnaire
Thank you for your interest in the California Public Employees’ Retirement System (CalPERS)
benefit programs. Please complete this School Applicant Questionnaire (Application) as
thoroughly as possible and provide supporting documentation for all responses. Your
application cannot be reviewed until all requested information has been provided. We ask that
you provide clear and complete answers to avoid delays in the review of your Application.
Once you submit your completed School Applicant Questionnaire, a CalPERS analyst will be
assigned to your case and will be available to assist you in the contracting process.
Keep in mind this Application is only the first step in the application process and we may
require additional information or supporting documentation from you as part of the application
process. CalPERS staff will contact you with more specific details on the contracting process
after we receive your completed Application and be available to you throughout the process.
Before fully reviewing your application information, we cannot guarantee you will be eligible to
contract with CalPERS for participation in the CalPERS benefit plans (CalPERS Plans). This
Application is not an offer to contract. Therefore, do not withhold and report CalPERS
retirement contributions from any of your employees in anticipation of eligibility to participate
in the CalPERS Plans, nor should you report your employees under any other agency currently
participating in the CalPERS Plans.
Agency Contact Information:
Official Agency:
Mailing Address:
Street Address:
City, State, Zip:
County:
Authorized Agency Representative:
Name:
Title:
Telephone:
E-mail:
January 2018
Page 1 of 5
Please provide complete copies of documents of creation such as the Articles of Incorporation,
Bylaws, any amendments, filings with the Secretary of State, and supporting documents such as
Board adoption resolutions and charter petitions as applicable. Please feel free to provide your
answers on additional pages, if necessary.
School Application Questions:
1. Are you a County Office of Education or Unified School District?
No.
Yes. If yes, you do not need to answer any additional questions. Please proceed to signing the
attached “Employer Certification” on page 4 of this application along with your supporting
documentation (e.g., bylaws, formation documents).
2. What type of entity is the school?
Public School
Charter School: if yes, please select organization type:
Non-Profit Corporation
For Profit
Other: If other, please describe:
3. Does a board or department of education, a county office of education or school district have
the power to nominate, appoint, remove, and replace a majority of the members of the school’s
governing board or body?
No.
Yes.
Are a majority of the members of the school’s governing board publicly nominated
and elected or appointed?
No.
Yes.
Publicly Nominated and Elected. Who nominated and elected the members?
Appointed. Who appointed the members?
Rev. Date January 2018
Page 2 of 5
4. Will the school’s net assets be distributed to a board or department of education, a
county office of education, school district, eligible public charter school or another
eligible public school should the school cease to exist?
No.
Yes. If yes, please describe in detail and reference Bylaws, contracts or agreements, or other
governing documents in the following table:
Affiliated Entities /
Relationship
References
Organizations
5. Please provide a detailed description of all sources of revenue or funding and expenditures,
including a description of any non-public sources, received or expected to be received by the
school to establish or operate the school, and percentage of each.
Percentage of Total Funding (all
Sources of Revenue/Funding
sources)
6. Does your school meet California Education Code standards for academics, financial
accountability, and health and safety standards?
No.
Yes.
Rev. Date January 2018
Page 3 of 5
7. Are any of the school’s employees currently participating in or reported to CalPERS by or
through another entity?
No.
Yes. If yes, please explain the current arrangement and identify any other entity(ies) or
organization(s) involved.
• How many total employees of the applying entity will participate in CalPERS?
8. Please submit yours or your parent organization’s recent Independent Auditor’s Report.
Rev. Date January 2018
Page 4 of 5
California Public Employees’ Retirement System
Financial Office | Pension Contract Management Services &
Prefunding Programs
P.O. Box 942709
Sacramento, CA 94229-2709
TTY: (877) 249-7442
888 CalPERS (or 888-225-7377) phone • (916) 795-4673 fax
www.calpers.ca.gov
Employer Certification
The undersigned hereby agrees and acknowledges that Employer is aware and understands that the
participation of its employees and retirees in one or more of the CalPERS benefit plans (CalPERS
Plans) is subject to, among other things, the determination of Employer’s eligibility to participate in a
governmental plan pursuant to the Internal Revenue Code (IRC). Employer acknowledges that the
Internal Revenue Service (IRS) is in the process of drafting regulations under Section 414(d) of the
IRC and that these regulations, when final, may impact Employer’s eligibility to participate in the
CalPERS Plans.
Employer understands that even if CalPERS determines that Employer is eligible to participate in
the CalPERS Plans based upon its good faith interpretation of existing IRS guidance, upon
publication of final Treasury Regulations pursuant to Section 414(d) of the IRC (Revised
Regulations), it may be determined that Employer would not be eligible to participate in a
governmental plan under such Final Regulations. Employer further understands that in the event of
such a determination, CalPERS will be obligated to comply with the Final Regulations and, if
required, terminate the Employer’s participation in the CalPERS Plans, including cancellation of all
benefits for employees and retirees of the Employer (Termination).
By executing this Certification below, the undersigned certifies that all information provided to
CalPERS in connection with Employer’s application to contract, including all information provided
in this Application, is true and correct. The undersigned agrees to update the information
contained in this Application within ten (10) calendar days of the date the undersigned knows or
should have known of any error or change to any information provided to CalPERS.
The undersigned certifies that he or she has been duly authorized by Employer to execute this
Certification on behalf of Employer.
I, the official named below, acknowledge and declare I have read and understand the Application and
Employer Certification. I am duly authorized to make this declaration on behalf of the above- named
Employer, and declare the foregoing is true and correct as of the date of execution of this document.
I further acknowledge my Employer’s responsibility to provide updates in the event this information is
determined to be incorrect or has changed.
Signature:
Name:
Title:
Date:
Rev. Date January 2018
Page 5 of 5