Employers' Pensions and Benefits Administration Manual (EPBAM)



Information by Employer Task


Employment Verification Form
for Service Credit Purchases

Instructions for the Employment Verification Form

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Employment Verification Form

Member Information

Provide basic member information requested.

Line 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 of Absence

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 (FICA).

13. Pension Fund Verification 

Check whether the employee was a member of a pension fund during any employment listed in Item 2. 

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!



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Last Updated: April 1, 2011