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Member Reciprocal Self-Certification Form

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California Public Employees' Retirement System Customer Account Services Division Retirement Account Services Section Box 942709. Sacramento, CA 94229-2709. TTY: (877) 249-7442. 888 CalPERS (or 888-225-7377) phone (916) 795-4166 fax Member Reciprocal Self-Certification FORM. Complete the following information and return this form to your Personnel Office within 10 business days: EMPLOYEE NAME: ________________________________________ ______________________________. (Last) (First) (Middle). SOCIAL SECURITY NUMBER OR CalPERS ID NUMBER: ______________________________________. NAME OF MOST RECENT Reciprocal RETIREMENT SYSTEM: _______________________________. PERMANENT SEPARATION DATE FROM MOST RECENT Reciprocal RETIREMENT SYSTEM: _____.

Contra Costa San Bernardino *City of Costa Mesa (Safety employees only) Fresno San Diego City of Fresno (Miscellaneous and . Imperial San …

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