1. Name of Employer
Please indicate the
full name of the employing agency.
Line 2. Payroll Title
Please enter the employee's
payroll title during the time period to be certified.
Line 3. Date of Hire
Please enter the date
on which the member was hired (MM/DD/YY).
Line 4. Date of Permanent Appointment
If the employee is/was
employed at a Civil Service location, please indicate in
this box the date on which permanent appointment was granted.
For non-Civil Service
locations, this date should be the same as the date of hire
into a regularly budgeted position. If the employee was hired
into a position that was not regularly budgeted (not immediately
eligible for enrollment), then the "date of permanent appointment"
would be the date when the employee first became eligible for
enrollment in a State-administered retirement system.
Line 5. Employment Dates
Please indicate the
beginning and ending dates of employment for each position (MM/DD/YY).
This should be broken down on a calendar year by year basis.
For board of education
positions the breakdown should be done by school year (Sept.-
June). If additional space is needed, attach an additional sheet
with all the information requested in items 2-7.
Line 6. Base Salary
Please enter the annual
or monthly salary earned for each year. Base salary is
the contractual salary of the employee. It should not include
bonuses, overtime pay, stipends or longevity pay, sick time, or
vacation time paid in a lump sum.
Be sure to indicate
whether the salary provided is monthly or annual.
7. Substitute Service
If the payroll title
indicated in item 3 is "Substitute" then the exact number
of days that the named employee worked during the regular school
year must be indicated in this item.
8. Board of Education Information
Board of education Certifying Officers
should indicate the number of months in the regular school year
for their particular district (i.e., 9, 10, or 11).
9. Dates for Leave of Absence
Enter the beginning and ending dates
of any leave of absence.
10 & 11. Reason for Leave
Enter the reason for each leave of
absence. Maternity leave (medical reasons) and child care leave
(personal reasons) are not the same kind of leave and should be
listed separately. Medical documentation should be noted and included
for leaves for medical reasons.
12. Social Security Coverage
Check whether the positions that
were listed in item 2 were covered under the provisions of Social
Security, also known as the Federal Old-Age and Survivors Insurance
System as defined in Section 218(b)5 of the Social Security Act
13. Pension Fund Verification
Check whether the employee was a
member of a pension fund during any employment listed in Item
If "yes", please
check whether the employee is receiving or entitled to receive
a pension based on the employment listed in Item 2. Also, please
provide the name and address of the retirement office.
14. Public/Private Employer
Check whether the employer is a public
or private entity.
The employer must be sure to sign
and date the Employment Verification Form. Unsigned Employment
Verification Forms will be returned. Title and phone number,
including area code, are also required.
Any alterations or corrections
must be initialed!