OFFICE OF COMPENSATION AND PROFESSIONAL STAFF …



Completing the Statement of Personal Ineligibility for Membership in PERS Form

Instructions for Completing the Form Electronically

This form is designed to be completed in Microsoft Word using the form completion feature. Use the tab key to move from field to field to enter the requested information. If you need to revise text that you have entered you can use your mouse to position your cursor in the field that you need to change.

The individual preparing the form follows these steps:

1. Save the downloaded form to a location where you can find it, if necessary.

2. If the cursor is not already in the first form field, place it there and enter the requested information.

3. Use the tab key to move to the next form field.

4. Upon completion of each field, use the tab key to move to the next form field until all of the relevant electronic fields have been completed.

5. Save the form to a directory where you can access it.

6. Print and sign the form.

7. Obtain Supervisor and Administrator signatures as necessary.

8. Route or process the form as required.

If you have questions about completing this form, please contact your Human Resources Operations office for assistance.

Please report any technical problems accessing or completing this form to uwhr@uw.edu.

Distribution: Return to the Benefits Office – Box 359556

University of Washington | Human Resources | Benefits

STATEMENT OF PERSONAL INELIGIBILITY FOR MEMBERSHIP IN THE

PUBLIC EMPLOYEES' RETIREMENT SYSTEM (PERS)

|section i – employee information |

|Last Name: |First Name: |Middle: |Student ID Number: |

|      |      |      |      |

|Social Security Number *: |UW Box Number: |

|    -    -      |      |

|Home Address: |City: |State: |Zip: |

|      |      |      |      |

|Employment Date: |Percent of Work Time: |Department: |

|      |      |      |

|Title: |Supervisor: |Work Phone: |Home Phone: |

|      |      |      |      |

| |

|section ii – certification |

|I hereby certify that I am: |______ |a full-time UW student |

| |______ |the spouse of the following full-time UW student |

| |Spouse Name (print or type): |______________________________ |

| |Spouse UW Student #: |______________________________ |

|________ |My employment is incidental to my/my spouse's education. I wish to be classified personally ineligible for membership in PERS and waive any |

| |claim to pension, annuity or disability benefits which might accrue to me as a result of participation in that system. |

| | |

| |I understand that I may later become a member of PERS if conditions change and I become a career employee. However, such membership shall be |

| |based only on service rendered subsequent to my enrollment date. |

| | |

| |In the event that I/my spouse cease(s) to be a full-time student, I agree to notify the Benefits Office immediately, because my continued |

| |employment at the University of Washington shall include membership in PERS. |

|________ |As a retiree of another State Retirement System: ______________________________ I am not |

| |eligible to be enrolled in PERS. |

|Employee Signature: _____________________________________________ |Date: ___________________ |

Please return to: Benefits Office

Box 359556

uw.edu/admin/hr/benefits/contacts.html

*Privacy Act Statement: Your Social Security number is required on this form to ensure compliance with Internal Revenue Code retirement tax reporting requirements.

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