Form Cs-377 - Certification Of Municipal Service/certification Of Elected Municipal Service
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1CS-377 (Rev - 03/09)
STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS
DEPARTMENT OF ADMINISTRATION
OFFICE OF PERSONNEL ADMINISTRATION
ONE CAPITOL HILL
PROVIDENCE, RI 02908
Check Appropriate Box(es):
Certification of Municipal Service
Certification of Elected Municipal Service
INSTRUCTIONS:
This form is used to verify service as a municipal employee and/or elected municipal official in order to determine a
current state employee's eligibility for additional vacation credit pursuant to Rhode Island General Law (RIGL) § 36-6-18
entitled "Additional Vacation Time for Career State Employees".
The above referenced statute applies to current State employees who were either hired or rehired after January 1, 2000, and
who were previously employed by a municipality or who served in an elected municipal office.
When the combined total of the employee's state service time and municipal service time is twenty (20) year or more,
the employee shall receive five (5) additional days each year, added to their vacation accrual which is based upon length of
State service, up to a maximum total accrual of twenty-eight (28) vacation days a year.
State service time and municipal service time is combined only in this instance (i.e. in order to determine eligibility for five (5)
additional vacation days.) State service time and municipal service time is NOT combined for the computation of
compensation or any other leave accrual.
In order to verify prior municipal employment or service, a current State employee may forward this form to the appropriate
municipal personnel officer. The State employee is responsible for tracking this form during the process.
The municipal personnel officer shall return the completed form to the State of RI Office of Personnel Administration at the
above address. The Office of Personnel Administration (OPA) will notify the employee and the Appointing Authority (designee),
of the decision which is made based upon the information provided on this form by the municipality.
PLEASE PRINT
Employee Information (completed by employee):
I, __________________________________________________, authorize release of the following information
(Employee Signature)
Employee Name__________________________________ Social Security Number_____________________________
Street____________________________City _______________________State__________Zip Code_______________
Employee Date of Birth __________________________
State Colleges
Department:
State Agency Presently employed:
U R I
Division:
Unit:
MUNICIPALITY EMPLOYED OR SERVED (completed by employee):
Title of Position or Office:
Dates Employed or Served*:
From______________To_______________
AGGREGATE TOTAL* Time (years, months, days) worked for employer (excluding
overtime)
*Elected municipal officials are granted Full Time status because of statutory provisions of continuous service.
Therefore, please specify term for elected officials.
Certified by Municipal Official: (Please type all information where applicable)
Name:______________________________________
Title:_____________________________________________________
Department/Agency ___________________________
Phone #:________________________________________________
Signature:___________________________________
Date:______________________________________________________
FOR USE OF PERSONNEL ADMINISTRATION ONLY - DO NOT WRITE IN THIS SPACE
Approved prior service
YES
NO
Time Credited ________________Years______________Months___________Days
Checked By:_________________________________Date:_________________
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Parent category: Business