407.06E - Licensed Employee Early Retirement Application

Name __________________________________________________________________

 

Birth date ________________________________________________________________

 

Social Security ____________________________________________________________

 

 

This application for early retirement constitutes a voluntary resignation effective at the end of the present contract year.

 

                                                                                                    _______________________________
                                                                                                     Signature

 

__________________________                                           _______________________________
Designated Beneficiary                                                                Witness

 

Signed before me on this ______day of ___________________, 20_____.

 

                                                                       

                                                                                                    ________________________________
                                                                                                    Notary Public

 

 

To be completed by Business Manager:

 

Years of employment within the district _______________________

 

Age, as of September 1^st, in which early retirement is granted _________________________

 

Severance payment                                    $35,000

 

Total unused sick leave days                     _______ X  20    15    10    5              ________________

 

Total benefits                                               Payment – January 20, 20____              ________________

                                                                       

 

 

Approved by Board action __________________              ___________________________________
                                                       Date                                                  Superintendent’s Signature