Calpers Member Action Request Form (Mar)
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1
2Division of Administration and Business Services
District Fiscal Services
Member Action Request
(Please type or print clearly)
1.
2.
3.
Current Name: (First Middle Last)
Social Security Number (SSN):
CalPERS ID (if available):
4.
5.
6.
Date of Birth (DOB):
Gender:
Former Name - For name changes only: (First Middle Last)
MM
DD
YYYY
Female Male
7.
8.
Mailing Address:
Remarks:
Street/P .O. Box:
9.
District Number/District Name:
Additional Address Line:
10.
City:
Job/Position Title:
State:
Zip Code:
Country: US
CA
11.
12.
13.
15.
Effective Date of Action:
Pay Frequency:
Retirement Code:
Hire Date:
MM
DD
YYYY
10 mo 11 mo
MM
DD
YYYY
14.
Classic New
12 mo
16.
Type of Action (check all boxes that apply for this Effective Date; if none apply, indicate action needed in “Remarks” [#8] above):
A. Appointment
D. Address Change
F. Profile Change
B. Membership Effective Date Change E. Permanent Separation
DOB (complete box 4)
C. Unpaid Leave of Absence
Separation Type:
Gender (complete box 5)
Begin Leave
Retirement
Name (complete box 6)
End Leave
Unused Sick Leave days:_____
SSN (complete box 8)
Death
Other:___________________
17.
18.
19.
20.
Survivor Benefits:
Covered by Social Security:
Retired Annuitant:
Retirement Election
Certificated Employee Electing PERS (ES 372)
Yes
Yes
Yes
Classified Employee Electing STRS (ES 372)
No
No
No
21.
Basis for Membership Qualification: (Check appropriate box.)
Full-Time for > 6 months
Has completed 1,000 hours or 125 days in fiscal year
Part-Time for ≥ 20 hours for 1 year or more
Person is already a PERS member
Indeterminate; at least 20 hours a week for 1 year or more
22.
Form Completed By:
Name: ______________________________________________ Title: _______________________________________________
Phone Number: _____________________________________ Fax Number: ________________________________________
Signature: __________________________________________ Date: ______________________________________________
FORM NO. 3331T (09/13)
Distribution: Original- DFS, Copy- Initiator
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Parent category: Legal