Fillable Prior Creditable State Service Verification Form printable pdf download

Reset Form

Print Form

N.C. Department of Health and Human Services (NC DHHS)

PRIOR CREDITABLE STATE SERVICE VERIFICATION FORM

Instructions: This form is used to verify if you have prior creditable state service (see the explanation and

definition of “Creditable State Service” on the BACK of this form). Complete Section A if you do not have prior

creditable state service or Section B if you do. Section C is to be completed by your previous employer.

Section A [To be completed by employee]

I have “No” prior “Creditable State Service” as defined on the back of this form. Return this form to the local (NC DHHS

division/facility/school human resources office).

_______________________________________

____________________________

Employee Signature

Date

Section B [To be completed by employee]

Complete the following information if you have prior creditable state service and submit this form to your previous

employer for verification of the dates of your employment. A separate “Prior Creditable Service Verification Form”

is required to be submitted to each of your previous employers for verification if you had more than one. Also,

submit completed Form 1A (see attached) to your local HR office.

Former Employer: ______________________________________________________________________________

Former Employer Address: _______________________________________________________________________

_______________________________________________________________________

Employer Phone #: ( _______)______________ Fax #: (________)__________________

Employee Name: _______________________________________________________________________________

(print full name as it appears on your social security card, maiden name, or other name used at the time of

employment)

Social Security Number: _________________________________________________________________________

Section C (Official Use Only) Instruction for Prior State or Local Employer Verification: Please verify the

above employee’s prior service with your agency by completing the information below.

Fax the completed information to the attention of:

NC DHHS Human Resources (division/facility/school name)

(Name of NC DHHS Human Resources employee)

Phone # (______)_______________

Fax # (_____)_________________________

Was the employee’s job and agency subject to the State Personnel Act?

Yes _____ No _____

Dates of Employment: From: _________________________ To: __________________________________

mm/dd/yy

Leave without Pay: From (if applicable): ________________To:__________________________________

mm/dd/yy

Full-Time ______ Part-Time______

If part-time, list number of hours per week: ______

(check the one that applies)

Leave Balances: Sick: _______Vacation: _______ Community Service: _______ Bonus: ________

FMLA: Date FMLA leave started: ___________ Used: __________ Remaining Balance Available: ___________

FIL: Date FIL leave started: _____________ Used: __________ Remaining Balance Available: ___________

Did the employee receive either full or partial longevity pay at the time of separation? Yes ___ No ___

If yes, give number of months and amount paid: Months ________ Amount ____________

I certify that the above information is accurate and complete:

________________________________________

__________________________________

____________

Human Resources’ Official Signature

Print Name

Date

________________________________________

Phone # ________________

Fax # _________________

Name of / Department/ Agency

Prior Creditable State Service Verification Form

Related Articles

Related forms

Related Categories