407.4E3 - Severance Plan Application Form

The undersigned licensed staff employee is applying for early retirement pay pursuant to board policy #407.4, Licensed Employee Early Retirement Plan.  Please complete the following information.

 

_________________________________________     _______________         _____________________
Full Legal Name of Licensed Employee                                Date of Birth                        Social Security Number

 

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

 

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

 

 

Independence Community School District (the “School District”) and Licensed Employee of the Independence Community School District (the “Employee”) agree as follows:

1.  In consideration of the benefits to be provided to him/her in accordance with the Early Retirement Plan, the employee agrees to immediately sign and submit a letter of resignation to be effective on June 30, 2021.

2.  The employee is advised that he/she has the right to consult with an attorney, tax advisor, or other professional prior to signing this Agreement.

3.  The employee hereby releases and discharges the School District, the Board of Directors of the School District, and any and all officers, employees, representatives or agents of the School District from any and all liability whatsoever including all claims, demands, or causes of action, including claims under the federal Age Discrimination in Employment Act which he/she has or may ever claim to have by reason of his/her employment with the School District and the termination of his/her employment relationship with the School District.

4.  The employee agrees that he/she will not apply for and will not be entitled to any re-employment by the District in any capacity, whether it is full time, part time or temporary.  If the District chooses to offer another position of employment in the future, however, this Agreement need not prevent such re-employment.

5.  The employee agrees that this Agreement is entered into freely and voluntarily and solely in reliance upon his/her own knowledge, belief and judgment and not upon representations made by the School District or others on its behalf.

6.  The employee shall have up to 45 days to consider this Agreement and, once approved and signed, he/she shall have up to 7 days to revoke this Agreement in writing. Thereafter, this Agreement will be effective once approved by the Board.

 

 

___________________________________                               ________________________
Signature                                                                                                              Date

 

 

__________ Approved

__________ Not Approved

 

 

___________________________________                               ________________________
Superintendent of Schools                                                                               Date