VERIFICATION OF NORTH CAROLINA STATE EMPLOYMENT



Compensation and Benefits

1901 Herbert Spaugh Lane

Charlotte, North Carolina 28208

Verification of Eligible North Carolina State Employment

Please read instructions on following page before filling out this form

Part I: Employee information (Must be completed by Employee)

_____________________________________________________ _______-______-_______

Last First Maiden or Middle Social Security Number

________________________________________ ________________ _______ _________

Street Address City State Zip Code

I was employed with __________________________________________________________________________

Previous Employer

as a __________________________________________ from ___________________ to ____________________.

Job Title Begin Date End Date

Part II: Confirmation of Employment (Must be completed by Previous Employer)

1. Employment Information:

|Dates of Employment |Employment Status |NC Retirement |Dates of Leave |

| | |Contribution |Without Pay |

|Begin Date |End Date |Part Time |Full Time |Yes |No |Begin Date |End Date |

| | | | | | | | |

| | | | | | | | |

| | | | | | | | |

2. Total Eligible NC State Service: ________________ Years ________________ Months

3. Was a longevity check issued when employee left your organization? ( Yes ( No

a. If yes, was it a: ( Full Check OR ( Partial Check

b. If partial check, please indicate the fraction of a full check. _______ Amount of Check? _______

c. What is the employee’s longevity date? ______________________

4. Leave Balances in Hours:

|Annual Leave Hours | |as of | |

|Sick Leave Hours | |as of | |

|Personal Leave Hours | |as of | |

5. Contact Information:

Completed By: ______________________________ Title: _________________________

School System / State Agency: _________________________________________________

Address: __________________________________________________________________

Phone Number: (_____)______-________ x _____ Fax Number: (_____)______-_______

Authorized Signature: ___________________________________ Date: _______________

NOTE: Please fax or mail this completed form directly to Charlotte-Mecklenburg Schools.

Explanation and instructions for Verification of Eligible NC State Employment form.

The Verification of Eligible NC State Employment form allows for the transfer of permanent part and/or permanent full time service (for NC State longevity purposes) and leave accruals from other NC school districts or NC State Agencies as outlined in the NC DPI Benefits and Employment Policy Manual.

NC does not allow for the transfer of leave accruals or service time from other states or countries.

It is each employee’s responsibility to procure verification of prior NC state service and/or the transfer of leave accruals and submit it through the Compensation Department (980)343-1847.

Total state service time affects the rate at which you earn annual leave as well as the rate you will be paid longevity once you have completed a total of 10 years of eligible North Carolina state service.

It does NOT, however, affect the years of experience on an educator’s license. An employee’s salary schedule step may not equal the number of state service years.

If you have prior NC state service, you must:

1. Complete Part I of the Verification of Eligible North Carolina State Employment form and send it to your previous state employer.

a. If there are multiple previous state employers, make copies of the blank form first. Then, complete a form for each previous state employer and send them to the corresponding state employer.

2. Your previous employer(s) should complete Part II of the form and submit it directly to Charlotte-Mecklenburg Schools by mailing it to the address listed below, by scanning it to the email address listed below or by faxing it to the fax number listed below.

scanned to: mycompensation@cms.k12.nc.us

faxed to (980)343-3165

Mailed to: Compensation Department

Charlotte-Mecklenburg Schools

1901 Herbert Spaugh Lane

Charlotte, NC 29208

Questions should be directed to (980)343-1847 or by email to mycompensation@cms.k12.nc.us

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