Form 1160 "Service Verification" - California

What Is Form 1160?

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:

  • 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 1160 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 1160 "Service Verification" - California

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P.O. Box 4000 Sacramento, CA 95812-4000
888 CalPERS (or 888-225-7377)
TTY: (877) 249-7442 | Fax: (916) 795-3389
www.calpers.ca.gov
Service Verification
Requesting System's Contact Information
TO:
Retirement Analyst:
Phone Number:
Fax Number:
REQUESTED EMPLOYMENT INFORMATION
(To be completed by the requesting retirement system)
Our member as of
has requested to purchase service credit for the following period(s) with our retirement system:
(Membership Date)
Member Name:
SSN: XXX-XX-
CID:
DOB:
Address:
City:
State:
Zip Code:
Employer
Position Title
Approximate Dates Requested
Status
Full Time
-
Part-Time
Full Time
-
Part-Time
Full Time
-
Part-Time
PRIOR EMPLOYMENT INFORMATION
(To be completed by the certifying retirement system)
1.
Current Status w/ your system:
As of:
2.
Employment History
Employer
Position Title
Dates of Employment
Service Refunded? Safety?
PEPRA?
Yes
Yes
Ye
s
-
No
No
No
Yes
Yes
Yes
-
No
No
No
Yes
Yes
Yes
-
No
No
No
Did this individual obtain membership in your retirement system?
YES*
NO
N/A
3.
*PLAN TYPE:
Defined Benefit
Defined Contribution
Other:
*Membership Date:
Is this member eligible to redeposit this service credit with your system?
YES*
NO
N/A
4.
*If Yes, will full reciprocal benefits apply?
YES
NO
*If a redeposit is elected, will the member be eligible to receive a benefit?
YES
NO
N/A
Has the member ever purchased/elected/pending purchasing service credit with your system?
YES
NO
N/A
5.
(Complete table)
Type of Purchase
Employer
Position Title
Period Dates
Service
-
-
6.
REMARKS:
CERTIFIED BY:
TITLE:
7.
8.
9.
PHONE:
(Print Name)
DATE:
RETIREMENT SYSTEM:
10.
11.
my|CalPERS 1160
P.O. Box 4000 Sacramento, CA 95812-4000
888 CalPERS (or 888-225-7377)
TTY: (877) 249-7442 | Fax: (916) 795-3389
www.calpers.ca.gov
Service Verification
Requesting System's Contact Information
TO:
Retirement Analyst:
Phone Number:
Fax Number:
REQUESTED EMPLOYMENT INFORMATION
(To be completed by the requesting retirement system)
Our member as of
has requested to purchase service credit for the following period(s) with our retirement system:
(Membership Date)
Member Name:
SSN: XXX-XX-
CID:
DOB:
Address:
City:
State:
Zip Code:
Employer
Position Title
Approximate Dates Requested
Status
Full Time
-
Part-Time
Full Time
-
Part-Time
Full Time
-
Part-Time
PRIOR EMPLOYMENT INFORMATION
(To be completed by the certifying retirement system)
1.
Current Status w/ your system:
As of:
2.
Employment History
Employer
Position Title
Dates of Employment
Service Refunded? Safety?
PEPRA?
Yes
Yes
Ye
s
-
No
No
No
Yes
Yes
Yes
-
No
No
No
Yes
Yes
Yes
-
No
No
No
Did this individual obtain membership in your retirement system?
YES*
NO
N/A
3.
*PLAN TYPE:
Defined Benefit
Defined Contribution
Other:
*Membership Date:
Is this member eligible to redeposit this service credit with your system?
YES*
NO
N/A
4.
*If Yes, will full reciprocal benefits apply?
YES
NO
*If a redeposit is elected, will the member be eligible to receive a benefit?
YES
NO
N/A
Has the member ever purchased/elected/pending purchasing service credit with your system?
YES
NO
N/A
5.
(Complete table)
Type of Purchase
Employer
Position Title
Period Dates
Service
-
-
6.
REMARKS:
CERTIFIED BY:
TITLE:
7.
8.
9.
PHONE:
(Print Name)
DATE:
RETIREMENT SYSTEM:
10.
11.
my|CalPERS 1160
INSTRUCTIONS
TITLE
DEFINITION
Indicate the member's current status and effective date of that status:
• Active: Membership date
• Inactive: Separation date
1.
Current Status w/ your system
• Inactive deferred: Separation date
• Refunded: Refund date
• Retired: Retirement date
Complete the table to document the member's employment history with your
2.
Employment History
system. (if there is additional employment periods, attach another document.)
Name of employer (Break out for different employers or for breaks in service
Employer
with the same employer).
Member's position title for the employment periods.
Position Title
(if unavailable, indicate "unknown")
Dates of Employment/ Membership
Dates of employment (from/to) with the employer
The years of service that were credited to the member as a result of
Service
employment and that could qualify them for vesting to retire.
Yes/No: Did the member terminate this employment period and refund their
Refunded?
contributions?
Yes/No: Was the employment period under a safety classification, i.e. law
Safety?
enforcement or active fire suppression or prevention?
Yes/No: Was the employment period under your system subject to the Public
PEPRA?
Employees' Pension Reform Act (PEPRA)?
Yes/No: Was the individual a contributing member of your retirement system?
Did this individual obtain membership in your
3.
If yes, indicate the type of plan, Defined Benefit, Defined Contribution, or other
retirement system?
retirement plan. Also, indicate the membership date in that plan.
Is this member eligible to redeposit this service credit Yes/No: If "Yes", indicate if full reciprocal benefits will apply. Also indicate if a
4.
with your system?
redeposit is elected, will the member be eligible to receive a benefit.
Yes/No: Did the member purchase additional service credit under your
Has the member ever purchased/elected/pending
5.
system? If yes, complete the table below. (if there are additional purchases/
purchasing service credit with your system?
elections, attach another document.)
Name of service credit purchase (i.e. Military, any service prior to becoming a
Type of Purchase
member)
Employer
Name of employer associated the service credit purchase (if applicable)
Position Title
Member's position title during the purchased service period (if applicable)
Dates associated to the service credit purchase (i.e. military service dates,
Period Dates
leave of absence dates)
Service
Number of years of service purchased
6.
Remarks
May be used to elaborate on any information indicated above.
7.
Certified By
Name of authorized personnel from the retirement system
8.
Title
Authorized personnel's position title
9.
Phone
Authorized personnel's direct business phone number
10.
Date
Date certified by authorized personnel
11.
Retirement System
Name of retirement system
my|CalPERS 1160
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