I hereby submit my formal application for participation in the voluntary early retirement program. This action is taken in accordance with the Board of Directors Policy No. 407.6 (Voluntary Early Retirement Program for Full-Time Staff).
My resignation from my contract with the District is attached and is made a part of this application. It is my understanding that this application and resignation will be acted upon simultaneously by the Board of Directors.
_________________________________________________ ________________
Signature of Employee Date
_________________________________________________ _________________
Signature of Witness Date
ELECTION OF BENEFIT
As a part of my application for the early retirement program, I hereby select the benefit option indicated below. All benefits are subject to Policy No. 407.6.
Date of Birth ___________________
II. A. Benefit for (Certified Teacher,
Administrator, or Support Staff) ___________________
II. B. Extra year’s Insurance Premium
Incentive ___________________
Sum of II. A. and II. B.
(Total Incentive Amount) ___________________
________ I hereby elect to receive group health insurance benefits in the amount of my benefit value.
_________________________________________________ ________________
Signature of Employee Date
DESIGNATION OF BENEFICIARY
I hereby designate _________________________________________________________
_____________________________________, ________________________________,
street address city
as my beneficiary.
________________________ ________________________________________
Date Signature of Employee
________________________ ________________________________________
Date Signature of Witness Date
RESIGNATION OF CONTINUING CONTRACT
I hereby submit my resignation from my position with the Gilmore City-Bradgate Community School District effective at the end of the current year.
_______________________________ ____________________________________
Date Signature of Employee
_______________________________ ____________________________________
Date Signature of Wittness
BOARD OF DIRECTORS ACTION
Dear______________________,
The Board of Directors of the Gilmore City-Bradgate Community School District approved the application for voluntary early retirement benefits and accepted the resignation from your position effective at the end of the current school year at their meeting held on ____________________________________.
_______________________________ ____________________________________
Date Board President
_______________________________ ____________________________________
Date Board Secretary
