Form Es 0350 - Permissive Membership printable pdf download

Permissive Membership

ES 0350 rev 02/17

California State Teachers’ Retirement System

P.O. Box 15275, MS 17

PERMISSIVE MEMBERSHIP ELECTION AND ACKNOWLEDGEMENT OF RECEIPT

Sacramento, CA 95851-0275

800-228-5453

OF CALSTRS DEFINED BENEFIT PROGRAM MEMBERSHIP INFORMATION

Employees who are employed to perform creditable service, but who are excluded from mandatory membership pursuant to Education Code sections

22601.5, 22602, or 22604, are eligible to permissively elect membership in the California State Teachers’ Retirement System (CalSTRS) Defined

Benefit Program pursuant to Education Code section 22515. This form enables eligible employees to make this election or decline to make this

election. This form must be received by CalSTRS within 30 days of the date on which the employee signs and dates the form. Contributions may not be

submitted to the system until CalSTRS has received the completed election form. If the employee elects membership in the CalSTRS Defined Benefit

Program, the membership date shall be the first day of the pay period following the date on which the employee signs and dates this form.

Section 1: Employee Information, Election and Certification

(to be completed by employee)

NAME (LAST, FIRST, MIDDLE INITIAL)

CLIENT ID OR SOCIAL SECURITY NUMBER

MAILING ADDRESS

HOME TELEPHONE

CITY, STATE and ZIP CODE

GENDER (circle one)

MALE

FEMALE

E-MAIL ADDRESS

BIRTH DATE (MM/DD/YYYY)



I elect membership in CalSTRS Defined Benefit Program

I understand this membership election is irrevocable and applies to all future employment to perform creditable service

with the same or another employer, and may be canceled only by terminating all such employment and receiving a refund of

my accumulated retirement contributions from CalSTRS.



I decline membership in CalSTRS Defined Benefit Program at this time

I understand I can elect membership in the Defined Benefit Program at any time while I am employed to perform creditable

service.

I certify I have received information from my employer concerning the CalSTRS Defined Benefit Program and understand the criteria for membership in

the program.

I understand it is a crime to fail to disclose a material fact or to make any knowingly false material statements for the purpose of altering or receiving a

benefit administered by CalSTRS and it may result in up to one year in jail and/or a fine of up to $5,000 pursuant to Education Code section 22010.

EMPLOYEE SIGNATURE

DATE

Section 2: Employer Certification

(to be completed by employer)

I certify that the above-named part-time or substitute employee has been provided with CalSTRS Defined Benefit Program membership criteria as

required pursuant to Education Code section 22455.5, and if applicable, informed of his or her right to elect into membership in the CalSTRS Defined

Benefit Program.

OFFICIAL’S SIGNATURE

DATE

OFFICIAL’S NAME

TITLE

COUNTY (or other employing agency)

DISTRICT

* MEMBERSHIP DATE (MM/DD/YYYY)

ASSIGNMENT (circle one)

EMPLOYEE

Part-Time

Substitute

* Effective January 1, 2017, permissive membership in the Defined Benefit Program shall become effective as of the first day of the pay period following

the employee’s election.

PERMISSIVE MEMBERSHIP • rev 02/17 • PAGE 1 OF 1

Form Es 0350 - Permissive Membership

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