Employer Certification Of Public Service Form
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4EMPLOYER CERTIFICATION
OF PUBLIC SERVICE
Defined Benefit Plan Participants — Government and Nonteaching
Part 1 — Completed by Member
(Please see Certification Form Instructions)
Member’s name ___________________________________________________________ STRS Ohio account no.
____________________
or
Address _________________________________________________________________ Social Security no. (last four digits) ____________________
Street
________________________________________________________________________
City
State
ZIP code
Email address ____________________________________________________________ Phone (_________) _______________________________
Area code
❏
❏
Current or past member of:
Ohio Public Employees Retirement System (OPERS)
School Employees Retirement System of Ohio (SERS)
Part 2 — Completed by Official Employer or Custodian of Records
(Please return form to member)
Employment must have been for a period of at least 12 consecutive weeks.
Complete name of the public agency __________________________________________________________________________________________
Complete address _________________________________________________________________________________________________________
Street
City
State
ZIP code
Type of service rendered ___________________________________________________________________________________________________
❏
❏
❏
Was this public service rendered for:
Federal government
Local government
State government
❏
Other (describe): ________________________________________________________________________
Record of purchasable service
(List each year of employment separately.)
Public service (nonteaching)
If teaching
Actual dates of service in
Complete appropriate column below
each STRS Ohio fiscal year*
Was this
employment
Number of
full time for
days employed
Days in
From
To
Clock hours
Number of days
the entire year?
within the
normal year
Mo
Da
Yr
Mo
Da
Yr
Position or title
if paid hourly
if salaried
(yes or no)
school year
of employment
*STRS Ohio Fiscal Years — Prior to 1974–75: September through August; 1974–75: September through June; 1975–76 and thereafter: July through June
❏
❏
Is there any type of retirement program (except Social Security) in effect now or in the future for the service listed above?
Yes
No
If yes, give the name of the retirement system:
___________________________________________________________________________________________________________________
I certify the statements and information completed above are correct according to the official records I have examined:
Print name _______________________________________________________________ Date __________________________________________
Official employer or custodian of records
Title ____________________________________________________________________ Phone (_________) ______________________________
Area code
Office _________________________________________________________________________________________________________________
Office address ___________________________________________________________________________________________________________
Street
City
State
ZIP code
15-128c, 12/15/200
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