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KPERS-1 Rev. 11/13
REPORT OF MEMBER STATUS
Instructions on page 2.
Contact Us –
toll free: 1-888-275-5737 • phone: 785-296-6166 • fax: 785-296-6638
e-mail: • web site: • mail: 611 S. Kansas Ave., Suite 100, Topeka, KS 66603
Important –
Employers complete this form to enroll new members or to report changes in a member’s employment
status. Receiving this information in a timely manner is essential for keeping employee records current. Please make sure that each
member is given the opportunity to complete a Designation of Beneficiary form (KPERS-7/99).
Part A – Member Information
1. Reason for Completing This Form (mark one):
Enroll a New Member
Transfer Membership
Return to Payroll
Report Dual Employment
2. If enrolling a new member, list employee’s membership date: ______/______/______
3. Social Security Number: ______-____-______
4. Name (First, MI, Last): ______________________________
5. Previous Name (if different): ________________________
6. Date of Birth: ______/______/______
7. Gender: Male
Female
8. Mailing Address: _________________________________
9. Employer: _______________________________________
City, State, Zip: ___________________________________
10. KPERS Employer Number: __________________________
11. Department Number: _____________________________
12. Membership Category (mark one): KPERS
KP&F
Judges
Elected Official
Legislator
13. Date Member Began Employment or Returned to Payroll in a KPERS-Covered Position: ______/______/______
14. For Employees on Military Leave Only (enter dates of leave without pay): _____/_____/_____ to _____/_____/_____
Please include a copy of the employee’s discharge papers (DD214).
15. For State of Kansas Correctional Employees Only (mark one): Group A
Group B
If reporting a group change, please select “Return to Payroll” above and mark the new group.
Part B – Service Information
1. Service With Current Employer:
Beginning and Ending Dates of Service (month/day/year)
Present Position: _________________________________
______/______/______ to ______/______/______
Former Position: __________________________________
______/______/______ to ______/______/______
Former Position: __________________________________
______/______/______ to ______/______/______
2. Comments: _____________________________________________________________________________________________
______________________________________________________________________________________________________
Part C – Designated Agent Statement
“I certify that the information provided on this form is true to the best of my knowledge. ”
Designated Agent Signature: ___________________________
Month/Day/Year: ______/______/______