The undersigned licensed employee is applying for early retirement pursuant to board policy 407.6, Licensed Employee Early Retirement. Deadline for submission: January
15 of the year in which the licensed employee wishes to retire. Please complete the following information:
______________________________________________________
(Full Legal Name of Licensed Employee)
______________________________ __________________________________
(Social Security Number) (Current Job Title)
________________ ____________________
(Date of Birth) (Years of Full-Time Service at North Mahaska
- not required to be consecutive years)
Please specify the date desired for payments of the early retirement benefit and the reason for the date if a date other than September 1 of each year beginning with the year in
which the undersigned licensed employee retires is desired.
______________________
(Date)
Reason for date other than September 1
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Payment Schedule:
Year 1: $10,000 HRA
Year 2: $10,000 HRA
Year 3: Balance HRA
Please attach a letter of resignation effective the date 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.
Licensed Employee Signature __________________________________ Date_______________
Board Secretary Signature: ____________________________________ Date_______________
