413.3E3 - Severance Plan Application Form

The undersigned classified employee is applying for early retirement pay pursuant to board policy #413.3, Classified Employee Early Retirement Plan.  Please complete the following information.

_____________________________________________     _______________         ________________________
Full Legal Name of Classified Employee                                          Date of Birth                       Social Security Number

 

 

_______________________________________        ____________________              _____________________
Current Job Title                                                                            Years of District Service               Years of IPERS Service
                                                                                                              By June 30th                               By June 30th

 

Please attach a letter of resignation giving the effective date of retirement from the district.

The undersigned employee acknowledges that application and participation in the early retirement plan is entirely voluntary.

The undersigned employee acknowledges that the school district recommends that the employee contact legal counsel and the employee’s own personal accountant regarding participation in the early retirement plan.

 

___________________________________                               ________________________
Signature                                                                                                     Date

 

 

__________ Approved

__________ Not Approved

 

 

___________________________________                               ________________________
Superintendent of Schools                                                                       Date