Fillable Verification For Employer Approved Leaves (Page 2 of 2) in pdf

VERIFICATION FOR EMPLOYER-APPROVED LEAVES

SC-1553(NEW 9/2007)

California State Teachers’ Retirement System

Service Credit Support, MS 88

P.O. Box 15275

Sacramento, CA 95815-0275

1 (800) 228-5453: TDD (916) 229-3541

PLEASE READ THE INSTRUCTIONAL TEXT BEFORE COMPLETING THIS FORM. TYPE OR PRINT LEGIBLY IN BLACK INK.

This form serves as verification for CalSTRS members who were on an approved leave of absence for one of the following types of leave: Maternity/Paternity,

leaves taken per the Family and Medical Leave Act (FMLA), Sabbatical and Federal Mutual Educational and Cultural Exchange Program (Fulbright).

NOTE: Employers may approve leaves for various reasons, such as personal leaves of absence, however the leaves listed on this form are the only employer-

approved leaves purchasable with CalSTRS.

Employers: Complete sections A, B and C then transmit this form via the Secure Employer Website (SEW) to CalSTRS. No further documents are required. However,

CalSTRS may contact you if there are any questions with the information provided. Members must still complete and send the Redeposit or Purchase Permissive Service

Credit form (MS0287) to CalSTRS.

CalSTRS Members: There are two ways to get this form to CalSTRS: 1) your employer can complete and transmit the form directly to CalSTRS as instructed above or

2) the completed form can be mailed/delivered to CalSTRS. If you choose the first option, contact your employer. Your employer will complete the entire form and

transmit it electronically to CalSTRS. For option 2, print out this form, complete Section A and have your employer complete Sections B and C. Once the form is

complete, you or your employer will need to mail/deliver the form to CalSTRS. In addition to this form, you must also complete and return the Redeposit or Purchase

Service Credit form (MS0287) to CalSTRS, before your request can be processed.

Section A

Employee Information

NAME

(Last)

(First)

(Initial)

SOCIAL SECURITY NUMBER or CLIENT ID

ADDRESS

(Number)

(Street)

(Apt #)

BIRTHDATE (mm/dd/yyyy)

(City)

(State)

(Zip Code)

TELEPHONE NUMBER

(

)

Section B

Leave Type and Date(s) (Please use mm/dd/yyyy format for dates)

Maternity/Paternity

Family and Medical Leave Act (FMLA)

per California Education Code § 22803(a)(9)

per California Education Code § 22803(a)(10)

From:________________________ To:_____________________

Sabbatical

Federal Mutual Educational/Cultural Exchange

per California Education Code § 22803(a)(7)

per California Education Code § 22803(a)(8)

From:________________________ To:_____________________

Use additional forms if more than two leaves per type are being verified.

Section C

Signature of Employer Representative

I certify that the information provided in Section B of this document was taken from the official records of this employer and that this employee met all the requirements for

this leave.

(

)

NAME OF EMPLOYER

TELEPHONE NUMBER

NAME OF EMPLOYER REPRESENTATIVE

TITLE

SIGNATURE OF EMPLOYER REPRESENTATIVE

DATE (mm/dd/yyyy)

VERIFICATION FOR EMPLOYER-APPROVED LEAVES • PAGE 1 OF 1