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 1st, 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
