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
