CC Resolution No. 52RESOLUTION NO. _
_
(To Accompany Applicaation and Agreement)
WHEREAS, a majority of the eligible employees for whom coverage is requested by the
hereinafter designated "Public Agency ",
Official Name of Public Agency
at an election or elections, voted in favor of the Public Agency making a formal applica-
tion to the Board of Administration of the State Employees' Retirement System, hereinafter
called "State ", for inclusion of the said eligible employees of said Public Agency in the
California State Social Security Agreement of March 9, 1951, providing for the coverage
of said eligible employees under the insura:ce system established by Title II of the
Federal Social Security Act; and
WHEREAS, the Public Agency desires to file such an application with the State and to
enter into an agreement with the State for inclusion of said eligible employees in said
California State Social Security Agreement; and
WHEREAS, official form "Application and Agreement, Ret. -OASI 32A" containing the
terms and conditions under which the State will effect such inclusion has been examined
by this body:
NOW, THEREFORE, BE IT RESOLVED that an Application and Agreement on said official
form be executed on behalf of the Public Agency and submitted to the State to provide
coverage under said California State Social Security Agreement as follows:
A. Coverage Groups (Check only one Iart):
1. All coverage groups, i.e., all eligible employees.
2, Q
Ret. -OASI 33A Rev. 5 (6 -57) 200 RESOLUTION (Other than Retirement System Members)
-2-
B. Excluded Services:
1. All services excluded from coverage under the agreement by Section 218
of the Social Security Act; and
2. Services excluded by option of the Public Agency (Check only one part):
Q a. No optional exclusions desired
L b. Service performed:
C. Effective Date of Coverage under Agreement Tn' -' -�' ''I s , 191 ;
BE IT FURTHER RESOLVED, that
Name
-- �Tit e of Position (Address of Public Agency)
be and he is hereby authorized and directed to execute said application and agreement on
behalf of and as Authorized Agent of the Public Agency and to forward same to the State
for acceptance and further action; and
BE IT FURTHER RESOLVED, that authority hereafter to act as Authorized Agent, and so
to conduct all negotiations, conclude all arrangements, submit all reports, and sign all
agreements and instruments which may be neceEsary to carry out the letter and intent of the
aforesaid application and agreement, in conformity with all applicable Federal and State
laws, rules and regulations, is vested in the position of "11 -t^
Title of Position
SUBMIT IN DUPLICATE
Ret. -OAST 33A Rev. 5 (6 -57)
, Clerk/Se TTwb%W of the
State of California, do hereby certify
the foregoing to be a full, true, and correct copy of Resolution No. adopted by
the of
of
the
At the regular/sF40iwl meeting held on
the . 14,a -'n- - day of as the same appears of record in my
office.
IN WITNESS WHEREOF, I have hereunto set my hand affixed the Seal of said
at my office this I day of
195 7
Clerk/t3eca-etar.y
SUBMIT IN DUPLICATE
Ret. OASI 33C Rev. 1 (7-57) 200 Certification