Redeposit Or Purchase Of Permissive Service Credit (Page 2 of 2) in pdf

Redeposit or Purchase of

Permissive Service Credit

continued

MEMBER’S NAME (LAST, FIRST, INITIAL)

CLIENT ID OR SOCIAL SECURITY NUMBER

Section 3: Permissive Service Credit

Time

Amount of

Frame

Type

Service

Comments

From — To

Credit

mm/dd/yy — mm/dd/yy

For example, substitute or part-time service in a California

Nonmember service

—

public school system prior to becoming a CalSTRS

❑

member.

If you previously worked under the Cash Balance Benefit

Cash Balance nonmember

Program and are now a Defined Benefit member, you can

❑

—

(previous CB participants only)

use your Cash Balance funds to purchase Defined Benefit

service credit.

Employer verification is required with this request.

Maternity or paternity leave

—

❑

Verification must be on:

•

CalSTRS Verification of Employer-Approved Leaves

form, or

FMLA- or CFRA-approved leave

—

❑

•

Employer letterhead with approved leave or absence

beginning and ending dates, a description of the

approved leave or absence, and the signature of an

authorized employer official.

Sabbatical leave

—

❑

Only for leaves approved by an employer in California.

Fulbright leave

—

❑

Employer verification of this service is required. You

must have been in a certificated teaching position in a

California child care center

—

❑

child care center operated by a county superintendent of

schools or a school district in California.

Employer verification of this service is required. You must

California Native

have been in a certificated teaching position in a federally

❑

—

American school

supported and administered Native American school in

California.

Employer verification of this service is required. You

California school for the

❑

—

must have been in a teaching position with the California

deaf or blind

School for the Deaf or the California School for the Blind.

Certain active U.S. military

❑

If prior to 1994, military order required (DD214). If after

service (must have membership

—

1994, see your employer.

in CalSTRS prior to joining)

Job Corps (must have

You must provide Job Corps certification letter. Write to:

❑

membership in CalSTRS prior

U.S. Department of Labor

to joining and service must have

—

Office of Job Corps

90 7th Street, Suite 12-100

been in a teaching position

in California)

San Francisco, California 94103

Peace Corps (must have

You must provide Peace Corps certification letter. Write to:

❑

Peace Corps Attn: Certifying Officer

membership in CalSTRS prior to

—

Volunteer & Staff Payroll Services Division

joining and service must have

been in a teaching position)

1111 20th St. NW Washington, DC 20526

Section 4: Signature

I understand that my signature does not create any obligation on my part to purchase this service credit.

MEMBER’S SIGNATURE

SIGNATURE DATE (MM/DD/YYYY)

REDEPOSIT OR PURCHASE OF PERMISSIVE SERVICE CREDIT • REV 01/17 • PAGE 2 OF 2

Redeposit Or Purchase Of Permissive Service Credit Page 2

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