407.6E3 - Licensed Employee Early Retirement Application

The undersigned licensed employee is applying for early retirement pursuant to board policy 407.6, Licensed Employee Early Retirement.  Please complete the following information:

______________________________________________     _________________________________
(Full Legal Name of Licensed Employee)                                                                     (Social Security Number)

______________________________________________     ________________      ______________
(Current Job Title)                                                                                                        (Date of Birth)                        (Years of Service)

Please specify the date desired for payment of the early retirement benefit and the reason for the date if a date other than _____________ of the year in which the undersigned licensed employee retires is desired.

______________  __________________________________________________________________
 (Date)                                      (Reason for date other than ______________)

Please attach a letter of resignation effective June thirtieth of the year in which the undersigned licensed employee intends to retire.

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

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

Should the licensed employee die prior to full payment of an early retirement benefit, the licensed employee designates either the following individual as beneficiary or the licensed employee’s estate.

____ Beneficiary                                          ____ Estate                                          

_________________________________________________________________________________
Beneficiary                                          

_________________________________________________________________________________
Beneficiary Address                                          

____________________________________________________________    ___________________
Licensed Employee                                                                                                                                 Date

____________________________________________________________    ___________________
Witness                                                                                                                                                                                       Date

  

 

Approved 2/13/06                
Reviewed _10/18/21
Revised ______________