Public Employees’ Benefits Program 901 S. Stewart St. Suite 1001 Years Of Service Form Carson City, NV 89701 www.pebp.state.nv.us First Day of Retirement (MM/DD/YYYY) Email: [email protected] Phone: 775-684-7000 or 1-800-326-5496 The "First Day Retired" is the first day you are in a retirement status with your retirement plan. 1 Participant Information (Please Print Clearly and Legibly) As a retired public employee, you may qualify for a premium subsidy based on each Nevada public employer with whom you earned service credit. In order to apply for a subsidy toward your retiree health insurance premium, please submit this form within 60 days of your retirement effective date. A subsidy will be applied to your premium cost upon the commencement of your retirement. The "First Day Retired" entered on this form is the first day you are in retirement status with your retirement plan. Note: The subsidy or contribution amount is determined using each full year of service credit (12 months) with a minimum of 5 years to a maximum of 20 years. Purchased service does not apply to the years of service subsidy or contribution allocation. Social Security Number (XXX-XX-XXXX) Date of Birth (MM/DD/YYYY) Male Female Last Name First Name Middle Initial 2 Enter the employer code and full name of each of your former Nevada public employers. Employer codes are included on the back of this form. If your former employer is not on the list, please write the full name of the employer without a code. Please list in descending order, starting with the name of your most recent Nevada public employer on the first line. If you worked for various state agencies within the State of Nevada, enter the total years that you worked for all state agencies on one line. List the number of years and months you worked for each Nevada public employer. Do not round days up to the next month. Do not round a month up to the next year. Example: You worked for the DMV from 03/26/92 (Mar. 1992) to 03/17/98 (Mar.1998) - this is equal to 5 years and 11 months of service. Employer Code Employer Name Years Months Years Months Enter any service credit that was purchased by you or on your behalf: Purchased: 3 Note: Do not list repayment of refunded contributions as purchased service credit. I acknowledge that the information provided is true. I understand that PEBP may verify this information with my retirement plan(s). Signature: _______________________________________________________ Date: Please SIGN and DATE and return to PEBP by mail -OR- email, doing both may delay enrollment. Incomplete or incorrect forms will be returned. 04/2021 v1 Nevada System of Higher 9858 9729 Douglas County School District 9870 Halima Ac.ademy 9886 Regional Plan Washoe County 9826 Elko Convention & Vis.itorsAuthcw"ity Education North fNon---PERS} I Can Do Anything White Pine County Tourism & 98S6 Legislative Retirement System 9742 Lander County School District 9792 9822 SeattyWater & Sanitation District 9810 Charter High School Recreation Board Use this code if you worked for a state department, division,. board, commission, 9999 Austin Volunteer Fire PERS, LCB, or you are a PERS retiree from 9761 Pershing County School District 9842 9703 Caliente Public Utilities 9747 Las Vegas Convention/Visitors Authority Department the Nevada System of Higher Education Nevada System of Higher Reno/Sp:arks Conventfon/Visitors 98S9 9742 Lander County School District 9721 City of Reno Firefigti.ters 9730 Douglas County Sewer District 9767 Education South (Non-PERS) Authority las Ve.gas Metropolitan 9713 Carson City 9744 Lincoln County School District 9749 98S3 Gerlach General Improvement District 9748 Clark County Housing Authority Police Department North Lyon County Fire 9712 City of Boulder 97S1 Lyon County School District 9699 9745 Lincoln County Power District 9748 North Las Vegas Housing Authority Protection District Tahoe-Douglas Fire 9790 City of Caliente 97S3 Mineral County School District 9TT3 9880 Mineral County Power 97S7 Nevada Rural HousingAuthority Protection District Churchill County Palomino Valley General Improvement 9716 City of Fallon 9781 White Pine County School District 9710 Volunteer Fire 9844 9748 Las Vegas Housing Authority District Department 9819 City of Fernley 9770 Storey County School District 988S Sierra Fire Prot District 9833 Mineral County Housing Authority Elko Volunteer Fire Carson-Truckee Water Conservancy 9719 City of North Las Vegas 9732 ElkoCountySchool District 9829 9706 9766 Reno Housing Authority Department District CityofWellsVolunteer Southern Nevada Regional Housing 9817 CityofWinnemucca 973S Esmeralda County School District 9723 9707 CC Communications 9748 Fire Department Authority Lovelock Volunteer Fire 9718 City of las Vegas 9736 Eureka County School District 9828 9879 Ely Water Department 9713 Carson City JRS Department Pershing Volunteer Fire 9818 City of Lovelock 9739 Humboldt County School District 9835 9837 Indian Hills Improvement District 9892 Lander Co Fair And Rec Department Winnemucca Rural 9786 City of Mesquite 97S9 Nye CountySchool District 9840 9811 Overton Power District i3 9746 Lincoln County JRS Volunteer Fire District Grass ValleyVolunteer Central Dispatch Administrative 9816 CityofWells 9777 Washoe County School District 9852 9812 Moapa Va Hey Water District 9846 Fire Department Authority Mason Valley Fire Pershing County Water Conservation 9724 CityofWestWendover 9727 Clark County 9902 9762 9722 CityofSpark:sJRS District District Mason Valley Fire 9720 City of Reno 9791 Esmeralda County 9901 9765 Regional Transportation Commission 9888 Elko Area Recreation Commission District ClarkCountyTeamAcademy, Clark Lovelock Meadows 9726 9750 Las Vegas/Clark County library District 9788 9768 Round Hill General Improvment 9834 East Fork Swimming Pool District County Water District No. Lake Tahoe Fire 978S City of Cartin 9867 OdysseyOiarterSchool 975S 9889 Northeast PN Develop 9718 CityofLasVegasJRS Protection District Coral AcademyofScienc,e Charter Rye Patch Volunteer Fire 971< CityofBk.o 9798 9893 9890 Tri-County Development Authority 9731 Douglas County JRS School Department Winnemucca Volunteer 971S CityofEty 980! High DeSert Montesscw-i School 9783 9814 Virgin Valley Water District 97S2 Lyon County JRS Fire Department MariposaAcademyoflanguageAnd Central Lyon County Fire 9860 CityofGabbs 9802 9700 9850 Canyon General Improvement District 9832 Churchill Mosquito Abate District Learning Protection District Battle Mountain General 9717 City of Henderson 9876 Rainbow Orea ms Academy 9702 9806 Clark County Water Reclamation District 9866 Elko Co School Lunch Prog:ram Hospital Humboldt General 9722 City of Sparks 9869 Silver State High School 9741 9823 Redevelopment Auth0<ity of Sparks 9857 Judicial Retirement System (State) Hospital Nye Re,giooal Medical 9731 Douglas County 9733 Elko County 9760 9884 Regional Water Planning 9898 Carson City Airport Authority Center Keystone AcademyOiarter High 9733 Elko County 9726 9780 Washoe County Hospital 9.SOA RTCofSouthern Nevada 9720 CityofRenoJRS School., aarkCounty Nevada Rural Heatth 97S2 Lyon County 9731 Douglas County 9861 9887 Tahoe Regional Plan 9737 Eureka County JRS Consortium Truckee Meadows Regional Planning 9809 Mineral County 9799 Bailey Charter Elementary School 970S Carson Tahoe Hospital 9836 9701 Airport Authority of Washoe County Agency Explore Knowledge Academy Charter Conservation District of Southern 9779 Washoe County 9801 9789 Lyon Health Center 9776 Walker River Irrigation District 9843 School Nevada Washoe County Water Conservation 9711 Churchill County 9796 Sierra Nevada Academy 9878 Pahrump Medical Center 9778 9808 Elko County Agricultural Assoc. District Nevada leadership Academy, Washoe William Bee Ririe 9727 Clark County 9777 9784 9841 Kingsbury General Improvement District 9895 Commission on Judicial Discipline County Hospital University Medical 9791 Esmeralda County 9868 RainshadowCharterSchool 9TTS Center of Southern 9827 Minden-Oardnerville Sanitation District 9891 LV Housing-Force Acct Nevada Clark County Heatth 9737 Eureka County 9872 Nevada State High School 9728 9881 Tonopah UtWties 9807 NEVAOAWORKS District MountGrantGeneral 9758 Nye County 9803 Academy for Career Education 9754 9883 So Nevada Water Authocity 9864 Wild Horse Preservatfon Commission Hospital Andre Agassi College Preparatory Pershing General 9763 Pershing County 9800 9764 982S Tahoe-Douglas District 9830 Nevada Association oi Counties Academy Hospital GroverC. Dils Medical 97<0 Humboldt County 9711 Churchill County 9738 9848 Truckee Meadows Water Authority 9713 RSVP Co:11lo:I 9743 Lander County 9874 100Academyof Excellence 9815 General Improvement 9882 Fernley Town Utilities 9851 Nevada Tahoe Conservation District District Carson Water Sub. McGill-Ruth Consolidated Sewer & 9746 Lincoln County 9873 Carson Montessori School 9820 984S 9877 Rural Bi-Co) Delinq Prev District Water General Improvement Gateways To Success Oiarter School, Sun Valley General Improvement Nevada Employment Security 9782 White Pine County 9709 9899 Clean Water Coalition 9772 9863 Churchill County District Department Gardnerville-Ranchos 9771 Storey County Southern Nevada W0<1cforce Investment 987S Innovations Charter 9838 General Improvement 9774 Truckee-Carson Irrigation District 9854 Soard ISNWIB) 9726 Clark County School District District Team A Was.hoe Charter School, lander County Sewer & 9704 CarsonCitySchool District 9777 9813 9862 Sou Ider City library District Washoe County Water Stagecoach General 9709 Churchill County School District 9871 Sierra Crest Academy 9831 9849 Henderson District Public libraries Improvement .