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Get CA CalPERS AESD-139 2011-2024

TEMPORARY CLASSIFIED NOTICE OF EXCLUSION FROM CalPERS MEMBERSHIP SOCIAL SECURITY NUMBER CURRENT NAME NAME OF PUBLIC AGENCY Your employer has contracted with the California Public Employees Retirement System CalPERS to provide an employee benefit package which includes service retirement death and disability benefits. LAST FIRST MIDDLE DEPARTMENT OR SCHOOL DISTRICT JOB OR POSITION TITLE IF TEMPORARY ENTER NEAREST NUMBER OF WHOLE MONTHS THE APPOINTMENT IS EXPECTED TO LAST. APPOINTMENT DATE DD YYYY MM Los Rios CCD TERM OF APPOINTMENT PERMANENT TEMPORARY MONTHS TIME BASE FULL-TIME INDETERMINATE PART-TIME IF PART TIME ENTER THE FRACTION OF FULL TIME In your present position with this agency you are excluded from CalPERS membership because 1. Your full-time seasonal or limited term appointment is limited to 6 months or less. 2. Your part-time appointment is limited to less than an average of 20 hours per week for less than one year. 3. Your appointment is an on-call intermittent emergency substitute or other irregular basis which excludes you from membership until you have worked 1 000 hours or 125 days if paid on per diem basis this fiscal year. 4. Your position is excluded by law or by contract agreement which excludes Enter contract exclusion for Public Agencies only. 5. You are an independent contractor. 6. You are employed to render professional legal service to a city. Exceptions Persons holding the office of city attorney deputy city attorney or assistant city attorney. only and you are attending school in the same district for County Schools only. NOTE If you are a member of CalPERS by previous employment either you have funds on deposit or service credit exclusions 1 2 and 3 do not apply to you and you should be a member Request Form or appoint via ACES to report your employment to CalPERS* If you believe that your employment does qualify you for CalPERS membership ask your employer for an explanation* If you still have doubts you may appeal directly to CalPERS by sending a letter to the Actuarial Employer Services Branch Membership Analysis Design Unit P. O. Box 942709 Sacramento CA 94229-2709 stating the reasons why you feel you should be a member. SIGNATURE OF CERTIFYING OFFICER TITLE DATE SIGNATURE OF EMPLOYEE NOTE Benefits provided by CalPERS are described in the CalPERS Benefits information booklet available from your employer. LAST FIRST MIDDLE DEPARTMENT OR SCHOOL DISTRICT JOB OR POSITION TITLE IF TEMPORARY ENTER NEAREST NUMBER OF WHOLE MONTHS THE APPOINTMENT IS EXPECTED TO LAST. APPOINTMENT DATE DD YYYY MM Los Rios CCD TERM OF APPOINTMENT PERMANENT TEMPORARY MONTHS TIME BASE FULL-TIME INDETERMINATE PART-TIME IF PART TIME ENTER THE FRACTION OF FULL TIME In your present position with this agency you are excluded from CalPERS membership because 1. APPOINTMENT DATE DD YYYY MM Los Rios CCD TERM OF APPOINTMENT PERMANENT TEMPORARY MONTHS TIME BASE FULL-TIME INDETERMINATE PART-TIME IF PART TIME ENTER THE FRACTION OF FULL TIME In your present position with this agency you are excluded from CalPERS membership because 1. Your full-time seasonal or limited term appointment is limited to 6 months or less. 2. Your part-time appointment is limited to less than an average of 20 hours per week for less than one year.

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