Parental Leave Service Credit Application - R0008c - State Of Michigan
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1
2Department of Technology, Management & Budget
Office of Retirement Services
(800) 381-5111
P.O. Box 30171
Lansing MI 48909-7671
Parental Leave Service Credit Application
For Public School Employees
MEMBER’S NAME (LAST, FIRST, M.I.)
DATE OF BIRTH:
MEMBER ID OR SSN
MAILING ADDRESS
ANTICIPATED RETIREMENT DATE:
DAYTIME PHONE NUMBER
(
)
CITY, STATE, ZIP CODE
PREVIOUS NAME(S) USED:
Section I – Member Certification
To be completed by applicant. See the back side for purchase requirements. Indicate the date(s) you separated from or
reduced your hours from public school service for parental leave purposes. If you worked for the State of Michigan and
separated for parental leave purposes, you may also be eligible to purchase that time. If the time you wish to purchase
includes multiple employers, complete and send an application to each employer. Be sure to list all employers and dates
on each application and attach a copy of your child(ren)’s birth certificate(s) or final adoption papers.
EDUCATIONAL OR STATE AGENCY YOU
DATE
EDUCATIONAL AGENCY WHERE YOU
DATE RETURNED/
SEPARATED/
SEPARATED/
RESUMED EMPLOYMENT
RESTORED
REDUCED HOURS FROM
REDUCED HOURS
HOURS
I certify that during the periods indicated above I did not work more than 20 hours per week for another employer and that the
above statements are true to the best of my knowledge and belief. I certify that my separation or reduction of hours was for
parental leave purposes only.
_________________________________________________________________________________________________________________
Applicant’s Signature
Date
If you have listed any time that you separated from a Michigan public school, Section II is required. If your parental leave
is for time you separated from State of Michigan service ONLY, Section II is not required.
Section II – Educational Agency Certification
To be completed by the educational agency only if the applicant is applying for time separated from a participating
Michigan public school. List the dates that the applicant separated or reduced hours from your agency for parental leave
purposes and, if applicable, when he/she returned. Return the form to the employee.
CERTIFYING EDUCATIONAL AGENCY
DATE SEPARATED/
DATE RETURNED/
REDUCED HOURS
RESTORED HOURS
SOURCE DOCUMENT (CHECK ONE)
PAYROLL RECORDS
PERSONNEL RECORDS
OTHER (SPECIFY
________________________________________________
I certify that the above applicant separated or reduced hours for parental leave purposes and the statements above are true to the
.
best of my knowledge and belief
_________________________________________________________________________________________________________________
Certifying Official’s Signature
Title
Date
_________________________________________________________________________________________________________________
Certifying Official’s Name (Print)
Address
Phone Number
After obtaining the above certification, refer to the Application Process on the backside to submit this form.
R0008C (Rev. 3/2015)
*0000180000000009*
Authority: 1980 P.A. 300, as amended
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