Employer Certification Of Termination And Accumulated Unused Leave

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Employer Certification of Termination and Accumulated Unused Leave

Form 18 – Revised 04/06/2015

Please print or type in black ink. Submit this form for terminated employees only; for retiring employees, submit Form 9A - Pre-Application

for Service Retirement Benefits. Completed form should be mailed or faxed to PERS. See bottom of form for contact information.



Member Information

First Name: ___________________________________________ MI: _______ Last Name: _________________________________________________

Social Security No.: ____________________________________________________ Date of Birth mm/dd/ccyy: __________________________________



Retirement Plan

–

Select applicable plan.

 Public Employees’ Retirement System of Mississippi (PERS)

 Mississippi Highway Safety Patrol Retirement System (MHSPRS)



Employer Certification

–

This section must be completed by an authorized employer representative, not the member. Employer certification is required

if date of termination of non-elected employee (member) is for purposes other than retirement and the leave cannot be transferred to another covered

employer. Do not include compensated leave, leave for which there are no records maintained by the employer, leave transferred to another employer,

leave other than personal or major medical leave, compensatory leave, leave donated to this employee from another employee, or leave which expired and

was not actually available for use by the employee.

Member’s Leave Payment

Member’s Lawfully Accumulated

Member information to be provided

by employer:

Not including compensatory leave payments

Unused, Uncompensated Personal

and Major Medical Leave

Member’s Position Held/Job Title:

If applicable, projected Gross Unreported Leave

Number of unused, uncompensated

Payment (Do not report payment for more than

personal and major medical leave days:

30 days/240 hours):

____________________________________

____________

$_______________________________

Leave accrual rate annually at

Lump sum leave payment rate of pay:

termination (express in hours, rather

Member’s Official Dates mm/dd/ccyy:

than days):

$_____________ per  Hour or  Day

Hire: ________________________________

_____________

Termination: __________________________

Employer Name: ____________________________________________________________ Employer No.: __________________ - _________________

Employer Representative’s Name: ________________________________ Employer Representative’s Title: _____________________________________

Employer Representative’s Phone: _________________________ Fax: __________________________ E-Mail: __________________________________

As employer representative, I understand that any person who makes a false statement or shall falsify or permit to be falsified any record of a retirement plan

administered by PERS in attempt to defraud the plan may be subject to criminal prosecution. With that understanding, I certify that the above employer

certification information is true and correct.

Employer Representative’s Signature: _______________________________________________________ Date mm/dd/ccyy: _______________________

Public Employees’ Retirement System of Mississippi

429 Mississippi Street, Jackson, MS 39201-1005

800.444.7377

601.359.3589

601.359.5262, fax

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