The undersigned licensed staff member is applying for early retirement pursuant to board policy 406, Licensed Staff - Termination of Employment. Please complete the following information:
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(Full Legal Name of Licensed Staff Member) |
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(Social Security Number) |
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(Current Job Title) |
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(Date of Birth) |
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(Years of Service) |
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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.
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(Date) |
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(Reason for date other than ______________) |
Please attach a letter of resignation effective June thirtieth of the year in which the undersigned licensed staff member intends to retire.
The undersigned licensed staff member acknowledges that application and participation in the early retirement plan is entirely voluntary.
The undersigned licensed employee acknowledges that the District recommends that the licensed staff member contact legal counsel and the staff member’s own personal accountant regarding participation in the early retirement plan.
Should the licensed staff member die prior to full payment of an early retirement benefit, the licensed staff member designates either the following individual as beneficiary or the licensed employee’s estate.
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____ Beneficiary |
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_____ Estate |
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Beneficiary |
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Beneficiary Address |
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Licensed Employee |
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Date |
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Witness |
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Date |
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