CC Resolution No. 04-271Return to:
California Public Employees' Retirement System
Actuarial and Employer Services Division
Public Agency Contract Services
P.O. Box 942709
Sacramento, CA 94229-2709
RESOLUTION 04-271
WHEREAS, the City of Cupertino ,
(Official Name of Public Agency)
hereinafter designated as "Public Agency", desires to establish a "deemed" retirement system
pursuant to Section 218(d)(6) of the Federal Social Security Act composed of positions of
members of the California Public Employees'
(Retirement System)
Retirement System, hereinafter designated "Present Retirement System", desiring "Medicare-
Only" coverage, and to include services performed by individuals employed by the Public
Agency in positions covered by said "deemed" retirement system, as members of a coverage
group established by Section 218(d)(4) of said Act, in the California State Social Security
Agreement of March 9, 1951, providing for the coverage of public employees under the Health
Insurance system established by said Act as amended; and
WHEREAS, State and Federal law and regulations require, as a condition of such
coverage, that a division be authorized by the Board of Administration, California Public
Employees' Retirement System; and
WHEREAS, it is necessary that the "Public Agency" now designate any services which it
desires to exclude from coverage with respect to such coverage group under said Health
Insurance system; and
PERS-MED-40D (12/94) - 1- DIVISION RESOLUTION (MEDICARE)
WHEREAS, it is necessary for the Public Agency to set forth the modification, if any, of
the benefits and contributions under the Present Retirement System that may result from
coverage under the said insurance system with respect to such coverage group;
NOW, THEREFORE, BE IT RESOLVED, that the Board of Administration, California
Public Employees' Retirement System, be and hereby is requested to authorize the foregoing
division; and
BE IT FURTHER RESOLVED, that upon receipt of authorization from the Board of
Administration a division shall be conducted in accordance with the requirements of Section
218(d) of the Social Security Act, and applicable State and Federal laws and regulations; that
each eligible member of the Present Retirement System at the time of the division shall be
furnished a form to permit the member to elect whether or not his services should be excluded
from or included under the said California State Social Security Agreement as hereinbefore
provided; with such "Medicare-Only" coverage effective as to services performed on and after
January 1, 2005 ; and
(Date)
BE IT FURTHER RESOLVED, that the following services with respect to said coverage
group of the Public Agency shall be excluded from coverage under said agreement:
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:
xx a. No optional exclusions desired.
b. Service performed:
PERS-MED-40D (12/94) -2- DIV1SION RESOLUTION (MEDICARE)
BE IT FURTHER RESOLVED, that with respect to the said coverage group the benefits
and contributions of the Present Retirement System shall not be modified in any way; and
BE IT FURTHER RESOLVED, that notice of the division shall be given to members of
the Present System not less than ninety days prior to the date of the division; provided however,
that notice shall be given to employees becoming members of the Present Retirement System
after the date of such notice up to and including the date of the division on the date on which they
attain membership in the system, and that Sandy Abe, Human Resources Manager
(Name and Title of Local Official)
is hereby designated and appointed to conduct such division on behalf of the Public Agency in
accordance with law, regulations, and this resolution, including the fixing of the date and the
giving of proper notice thereof to members of the Present Retirement System and to all such
eligible employees; and
BE IT FURTHER RESOLVED, that the Public Agency will pay and reimburse the State
at such time and in such amounts as may be determined by the State the approximate cost of any
and all work and services relating to such division.
Presiding Officer
City of Cupertino
Official Name of Public Agency
PERS-MED-40D (12/94) -3- DIVISION RESOLUTION (MEDICARE)
City Clerk
I, Kimber ly Smith , '
0 ame)
Of the City of Cupertino
hereby cer~fy the foregoing to be a ~I1, ~e, ~d co~ct copy of R~solution No.
~opt~d by ~ City Council of ~c
CitY of Cupertino
thc 17th day of February
(Title)
, StYe of C~ifomi~ do
04-271
at the regular/M~oia!-meeting held on
2004 , as the same appears of record in my
office.
IN WITNESS WHEREOF, I have hereunto set my hand and affixed the se~ of s~d
City of Cupertino , ~my office this 19th day of
2004
February ,
(Signature)
(Title)
I
PERS-MED-40D (12/94) -4- DIVISION RESOLUTION (MEDICARE)