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Member Reciprocal Self-Certification Form

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: _____.

in retirement agreements with other systems. County of San Luis Obispo . East Bay Municipal Utility District . State Teachers’ Retirement System East Bay Regional Park District

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