The undersigned licensed employee is applying for early retirement pursuant to board policy 407.4, Licensed Employee Early Retirement. Please complete the following information:
___________________________________________ ____________________________
Full Legal Name of 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 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:___________________