Fillable Form 6000 - Notification of Retirement: Notification of (Commonwealth of Kentucky)

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Form 6000 - Notification of Retirement: Notification of (Commonwealth of Kentucky)

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Country of origin: US
File type: PDF

U.S.A. forms for Commonwealth of Kentucky

BROWSE COMMONWEALTH OF KENTUCKY (KY) FORMS

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Ready to retire? Completing this form is your first step. Please call our office at 1-800-928-4646 if you have questions
or if you need assistance completing forms. Members are encouraged to visit our website at kyret.ky.gov for
additional information.
Revised 6/2019
For insurance coverage to begin the same month as your retirement payment, you must file a Form 6200 with
our office by the last day of the month prior to the month you retire. For example:
Retirement Date Application Due By Insurance Effective Date
May 1 April 30 May 1
If you miss the above deadline, you can still submit an application. Your Form 6200 must be filed with our
office within 30 days of the first day of the month in which you retire. For example:
Retirement Date Application Due By Insurance Effective Date
May 1 May 30 June 1
Insurance Application Deadlines
Additional instructions are provided on the following page. Keep reading to find out your deadline for
returning retirement forms.
The Form 6000 contains several sections. Please review this form carefully and refer to the instructions for each
section. Additional instructions for completing Section G - Tax Withholding are provided on page 3.
Date of Birth Verification for Member and Beneficiary is required.
Please write your Member ID on all copies you submit.
Acceptable forms of date of birth verification include the following:
• Kentucky Driver's License • Military Discharge
• Birth Certificate • Immigration and Naturalization Records
• U.S. Passport • Age record of the Social Security Administration
You should submit your Form 6000 at least one month prior to your effective retirement date. Please note that you
cannot file your Form 6000 more than 6 months prior to termination of employment.
Form 6000 - Notification of Retirement
Your Member ID is a unique account number for your KRS account. If you received this form from our office, your
Member ID is provided. If you access this form from our website and don't know your Member ID, you can contact our
office at 1-800-928-4646. You will need to provide your Social Security Number and your four-digit KRS PIN to obtain
your Member ID.
Your Member ID
Instructions / Page 1
If you will be receiving a monthly payment, you may be eligible for health insurance coverage for you, your spouse,
and eligible dependents. KRS offers Medicare and non-Medicare plans. You may access insurance applications and
enrollment booklets by visiting our website at kyret.ky.gov. Please call our office to request a printed copy.
Form 6200 - Insurance Application
You must return an insurance application by the deadlines described below, even if you wish to waive
coverage. If you fail to return a completed application, you will be enrolled automatically into a default plan
for the current plan year. If you choose not to participate in the coverage, you will need to complete the Form 6200
to waive your coverage; otherwise, you will be enrolled automatically into a default plan as described above.
Notification of Retirement Instructions
If you elect to receive a monthly benefit, complete and return the following:
Form 6010, Estimated Retirement Allowance
Form 6200, Insurance Application (refer to insurance application and deadlines on page 1)
All required forms and documentation must be filed with our office by the last day of the month
prior to your effective retirement date. You are responsible for filing your insurance application
prior to the deadlines noted on page 1 or you will be enrolled automatically into a default plan.
If you have any questions, please contact our office at (502) 696-8800 or (800) 928-4646.
Our office is open from 8:00 am to 4:30 pm Monday through Friday.
Retirement Date Due Date
January 1 December 31
February 1 January 31
March 1 February 28
April 1 March 31
May 1 April 30
June 1 May 31
July 1 June 30
August 1 July 31
September 1 August 31
October 1 September 30
November 1 October 31
December 1 November 30
Instructions / Page 2
Once we process your Form 6000, we will send you additional forms for completion. The checklists below will help
you decide which forms you need to return to our office.
If you elect to receive an actuarial or lump sum refund** complete and return the following:
Form 6010, Estimated Retirement Allowance
Form 6025, Direct Rollover/Direct Payment Election
**We require additional verification from your employer before we can process a refund which may delay your check.
Upon receipt of the above forms, we will mail required forms to you and your employer for completion.
Your Next Step: Check your mailbox.
A
Enter “1” for yourself
. . . .
.
. . . . . .
. . .
. .
. .
.
.
.
.
.
....
..
..
A
B
• You're single, or married filing separately, and have only one pension; or
• You're married filing jointly, have only one pension, and your spouse has
no income subject to withholding; or . . . . . . . .
• Your income from a second pension or a job or your spouse’s pension or
wages (or the total of all) is $1,500 or less.
B
C
D
E
• If your total income will be less than $71,201 ($103,351 if married filing jointly), enter “4” for each eligible child.
F
G
• If you have more than one source of income subject to withholding or are married filing
jointly and you and your spouse both have income subject to withholding and your
combined income from all sources exceeds $53,000 ($24,450 if married filing jointly), see the
Multiple Pensions/More-Than-One-Income Worksheet on page 5 to avoid having too little tax withheld.
• If neither of the above situations applies, stop here and enter the number from line H on line
2 of Form W-4P above.
D
Enter “1” if:
C
Child tax credit. See Pub. 972, Child Tax Credit, for more information.
E
F
• If your total income will be from $71,201 to $179,050 ($103,351 to $345,850 if married filing jointly), enter “2”
for each eligible child.
• If your total income will be from $179,051 to $200,000 ($345,851 to $400,000 if married filing jointly), enter “1”
for each eligible child.
Your monthly retirement benefit is subject to federal taxes. You may choose your federal tax withholding preference
by completing Section G of your Form 6000, Notification of Retirement. If you do not complete Section G, KRS
will automatically withhold federal income tax based on married status with 3 exemptions. You may find the
worksheets below helpful when completing Section G.
Additional information is available on the Internal Revenue Service website at www.irs.gov.
Purpose. Form W4-P is for U.S. citizens, resident aliens, or their estates who are recipients of pensions, annuities
(including commercial annuities), and certain other deferred compensation. Use Form W4-P to tell payers the correct
amount of federal income tax to withhold from your payment(s). You also may use Form W4-P to choose (a) not to have
any federal tax withheld from the payment (except for eligible rollover distributions or payments to U.S. citizens delivered
outside the United States or its possessions) or (b) to have an additional amount of tax withheld.
What do I need to do? Complete lines A through H of the Personal Allowances Worksheet. Use the additional
worksheets on the following page to further adjust your withholding allowances for itemized deductions, adjustments to
income, any additional standard deduction, certain credits, or multiple pensions/more-than-one-income situations. If you
do not want any federal income tax withheld (see Purpose, earlier), you can skip the worksheets and go directly to the
Form W4-P, Section G of the Form 6000.
Future developments. For the latest information about any future developments affecting Form W-4P, such as
legislation enacted after we release it go to www.irs.gov/w4p.
Instructions / Page 3
Form W4-P Instructions
For accuracy,
complete all
worksheets
that apply.
Enter “1” if you will file as head of household .
Enter “1” if you will file as married filing jointly.
• If your total income will be higher than $200,000 ($400,000 if married filing jointly), enter “-0-”
G
Credit for other dependents. See Pub. 972, Child Tax Credit, for more information.
• If your total income will be less than $71,201 ($103,351 if married filing jointly), enter “1” for each eligible dependent.
• If your total income will be from $71,201 to $179,050 ($103,351 to $345,850 if married filing jointly), enter “1”
for every two dependents (for example, "-0-" for one dependent, "1" if you have two or three dependents, and
"2" if you have four dependents).
• If your total income will be higher than $179,050 ($345,850 if married filing jointly), enter "-0-"
Other credits. If you have other credits, see Worksheet 1-6 of Pub. 505 and enter the amount from that worksheet here.
H
Add lines A through G and enter the total here
H
• If you plan to itemize or claim adjustments to income and want to reduce your
withholding, or if you have a large amount of other income not subject to withholding and want to increase
your withholding, see the Deductions, Adjustments and Additional Income Worksheet, later.
.
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Personal Allowances Worksheet (Keep for your records.)
Form W-4P Instructions Continued
Instructions / Page 4
Note. Use this worksheet only if you plan to itemize deductions, claim certain adjustments to income or have a large amount of
other income not subject to withholding.
1
...........
...........
2
Enter:
$24,400 if you're married filing jointly or qualifying widow(er)
$18,350 if you're head of household .. . . . . . . . . . .
$12,200 if you're single or married filing separately
2
$
3 Subtract line 2 from line 1. If zero or less, enter “-0-” .
. . . . . . . . . . . . . . . .
3
$
4
Enter an estimate of your 2019 adjustments to income, qualified business income deduction, and any additional
standard deduction for age or blindness (see Pub. 505 for information about these items)
. . . . . . .
4
$
5
Add lines 3 and 4 and enter the total
5
$
6
6
$
7
7
$
8
8
9 Enter the number from the Personal Allowances Worksheet, line H, page 4 .
. . . . . . . .
9
10
Add lines 8 and 9 and enter the total here. If zero or less, enter "-0-". If you plan to use the Multiple
Pensions/More-Than-One-Income Worksheet, also enter this total on line 1 below. Otherwise, stop
here and enter this total on Form W-4P, line 2, page 1
. . . . . . . . . . . . . . . . .
10
have more than one source of income subject to withholding (such as more than one pension, or a pension and a job, or you have a pension and your spouse works).
1
2
2
If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter
"-0-") and on Form W-4P, line 2, page 1. Do not use the rest of this worksheet.
. . . . . . . .
3
4
Enter the number from line 2 of this worksheet . . . . . . . . . .
4
5
Enter the number from line 1 of this worksheet . . . . . . . . . .
5
6 Subtract line 5 from line 4 .
. . . . . . . . . . . . . . . . . . . . . . . . .
6
7 Find the amount in Table 2 below that applies to the HIGHEST paying pension or job and enter it here
7
$
8 Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed
8
$
9 Divide line 8 by the number of payments remaining in 2019. For example, divide by 8 if you're paid
every month and you complete this form in April 2019. Enter the result here and on Form W-4P, line 3,
page 1. This is the additional amount to be withheld from each payment.
9
$
Table 1
Married Filing Jointly
If wages from LOWEST
paying job or pension are
—
Enter on
line 2 above
All Others
If wages from LOWEST
paying job
or pension
are—
Enter on
line 2 above
Table 2
Married Filing Jointly
If wages from HIGHEST
paying job
or pension
are—
Enter on
line 7 above
All Others
If wages from HIGHEST
paying job
or pension
are—
Enter on
line 7 above
Enter an estimate of your 2019 itemized deductions. These include qualifying home mortgage interest,
charitable contributions, state and local taxes (up to $10,000), and medical expenses in excess of 10% of
your income. See Pub. 505 for details
Deductions, Adjustments, and Additional Income Worksheet
..
$420
500
910
1,000
1,330
1,450
1,540
$0 - $7,200
7,201 - 36,975
36,976 - 81,700
81,701 - 158,225
158,226 - 201,600
201,601 - 507,800
507,801 and over
$420
500
910
1,000
1,330
1,450
1,540
$0 - $24,900
24,901 - 84,450
84,451 - 173,900
173,901 - 326,950
326,951 - 413,700
413,701 - 617,850
617,851 and over
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
$0 - $7,000
7,001 - 13,000
13,001 - 27,500
27,501 - 32,000
32,001 - 40,000
40,001 - 60,000
60,001 - 75,000
75,001 - 85,000
85,001 - 95,000
95,001 - 100,000
100,001 - 110,000
110,001 - 115,000
115,001 - 125,000
125,001 - 135,000
135,001 - 145,000
145,001 - 160,000
160,001 - 180,000
180,001 and over
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
$0 - $5,000
5,001 - 9,500
9,501 - 19,500
19,501 - 35,000
35,001 - 40,000
40,001 - 46,000
46,001 - 55,000
55,001 - 60,000
60,001 - 70,000
70,001 - 75,000
75,001 - 85,000
85,001 - 95,000
95,001 - 125,000
125,001 - 155,000
155,001 - 165,000
165,001 - 175,000
175,001 - 180,000
180,001 - 195,000
195,001 - 205,000
205,001 and over
$
. . . . . . . . . . . . . . .
.........
Subtract line 6 from line 5. If zero, enter “-0-”. If less than zero, enter the amount in parentheses
Divide the amount on line 7 by $4,200 and enter the result here. If a negative amount, enter in
parentheses. Drop any fraction
. . . . . . . . . . . . . . .
..........
Multiple Pensions/More-Than-One-Income Worksheet
Note. Use this worksheet only if the instructions under line H,from the Personal Allowance Worksheet, direct you here. This applies if you (and your spouse if married filing jointly)
Enter the number from the Personal Allowances Worksheet, line H, page 4 (or from line 10 above if
you used the Deductions, Adjustments, and Additional Income Worksheet) .
1
Find the number in Table 1 below that applies to the LOWEST paying pension or job and enter it here.
However, if you're married filing jointly and the amount from the highest paying pension or job is $75,000 or
less and the combined amounts for you and your spouse are $107,000 or less, do not enter more than "3"
3
Note. If line 1 is less than line 2, enter “-0-” on Form W-4P, line 2, page 1. Complete lines 4 through 9 below to figure the additional
withholding amount necessary to avoid a year-end tax bill.
. ..
. . . . . . . .
. . . . . . . . .
Enter an estimate of your 2019 other income not subject to withholding (such as dividends, interest, or capital gains)
1
Form 6000
Revise 6/2019
Member Name: Member ID:
Address: City:
State: Zip Code:
Section A: Member Information
You must attach a copy of your birth verification.
E-mail:
Phone:
Date of Birth:
Sex:
Male
Female
Notification of Retirement
Please read the instructions for each section and complete all information requested in Sections A-G.
Section H must be completed by your current employer. Section I must also be completed if applying for
disability retirement.
Section B - Type of Retirement
If applying for normal or early retirement, you may not submit this form more than 6 months prior to termination of
employment. You must terminate your employment to be eligible for early or normal retirement benefits.
NORMAL OR EARLY RETIREMENT DISABILITY RETIREMENT
Disability Retirement applicants must complete Section I.
Kentucky Employees Retirement System - KERS (state employees, health departments, universities)
County Employees Retirement System - CERS (city, county, local governments, classified employees of boards of education)
State Police Retirement System - SPRS (full-time officers of Kentucky State Police)
Other State Administered Retirement Systems
If you have an account in one of the systems administered by Kentucky Retirement Systems (KERS, CERS, or SPRS) and in
one of the other state administered retirement systems (listed below), you will need to complete the retirement application for
the other system in order to be eligible for reciprocal benefits from all systems.
Teachers' Retirement System - TRS (certified employees of boards of education)
Legislators' Retirement Plan - LRP (State Senators and Representatives)
Judicial Retirement Plan - JRP (Judges)
Section C: Retirement Systems
Check the appropriate box or boxes to indicate the retirement systems from which you intend to retire.
You must provide a termination date and retirement date below.
(YOUR TERMINATION DATE MUST BE PRIOR TO YOUR RETIREMENT DATE.)
Termination Date:
Month Day Year
(YOUR RETIREMENT DATE MUST BE THE FIRST DAY OF THE MONTH.)
Retirement Date:
Month
1,
Year
Form 6000
Page 1
Please note: If your current legal name or your beneficiary's current legal name is not the same as the name on the date of birth
verification you have submitted we will also require verification of name change. Acceptable name change verification includes:
• Kentucky Driver's License
• Marriage Certificate
• Court Order
• Passport
• Immigration and/or Naturalization Documents
Section D - Retirement Account Beneficiary Designation
Your account beneficiary can only be one person, a trust or your estate. Indicate your beneficiary by checking one of
the beneficiary types below and providing the necessary information. This designation will become invalid if you file a
new Form 6000 prior to your effective retirement date or if this form is voided.
Member ID:Member Name:
Attach a copy of this person's birth verification to this form with your Member ID written on it.
Name:
Date of Birth:
Relationship:
Address: City: State: Zip Code:
Male Female
Check this box if this person is also your legal spouse.
Person
Social Security Number:
No additional information required. My Estate
Form 6000
Page 2
A testamentary trust is established by the member's will and takes effect following the member's
death. No additional information required.
Testamentary Trust
City:
The following information is required to designate a living trust. You must write the name of the trust as it
appears in the trust document and submit a copy of the trust with this form. A charitable organization or a religious charity cannot
be named as beneficiary unless it is a trust.
Trust Tax ID:
Living Trust
Zip Code:State:
Address:
Trustee:
Trustee or Successor Trustee Contact Information: Our office will contact the trustee listed below following your death.
Name of Trust:
Successor Trustee (if applicable):
Please enclose a copy of the Funeral Home License with your Member ID written on it.
A testamentary trust is established by the member's will and takes effect following the member's
death. No additional information required.
No additional information required.
You may only name one person as your death benefit beneficiary.
Zip Code:State:City:Address:
Social Security Number:Name:
Date of Birth:
Relationship:
Zip Code:State:City:Address:
Successor Trustee (if applicable): Trustee:
Name of Trust:
Zip Code:State:City:Address:
Funeral Home License Number:Funeral Home Legal Name:
Funeral Home Tax ID:
Contact Name:
Phone:
Male Female
Trustee or Successor Trustee Contact Information: Our office will contact the trustee listed below following your death.
The following information is required to designate a living trust. You must write the name of the trust as it
appears in the trust document and submit a copy of the trust with this form. A charitable organization or a religious charity cannot
be named as beneficiary unless it is a trust.
Person
My Estate
Living Trust
Funeral Home
Testamentary Trust
Section E - $5000 Death Benefit from Kentucky Retirement Systems - Complete only if eligible
To be eligible for this benefit, you must be a retired member receiving a monthly benefit on the date of your death from
Kentucky Retirement Systems based on a minimum of 48 months of service.
Trust Tax ID:
Member ID:Member Name:
If eligible for this benefit, you may name one death benefit beneficiary. This designation is not valid if you designate more than
one beneficiary. Your estate will become your default beneficiary if this designation is deemed to be invalid. This designation may
be changed at any time prior to your death by filing a properly completed Form 6030, Death Benefit Designation.
Form 6000
Page 3
If all required forms have been completed properly and returned by the end of the month prior to your retirement date,
the first check will be deposited or mailed on the 14
th
of the first month of retirement. Due to deadlines required to
establish a direct deposit, your first benefit payment is not guaranteed to be deposited to your account.
Many benefit payments for the first month of retirement are mailed. After the initial payment, the monthly benefit will
be deposited to the retired member's account on the 14
th
of each month. If the 14
th
of the month is a weekend or
holiday, the benefit will be mailed or deposited the business day prior. Members are required to have the monthly
retirement benefit deposited directly to their bank accounts, unless their bank does not participate in the Automated
Clearing House or the member does not have an account with a financial institution.
Section F - Authorization for Deposit of Retirement Payment
Complete this section to authorize deposit of your retirement benefit directly into your account at a financial institution.
Financial Institution Name:
Depositor Routing Number:
Depositor Account Number:
Account Type:
Checking Savings
For your convenience:
The sample check shows where to locate
the required bank information to complete
your Direct Deposit.
a VOIDED personalized check verification from my financial institution
verification from my financial institution
For deposits to a Checking Account:
I have attached to this form
For deposits to a Savings Account:
I have attached to this form
Financial Institution Information: The financial institution may be a bank, savings bank, savings and loan association, credit union,
or similar institution that is a member of the Automated Clearing House (ACH). Your direct deposit institution may be changed at
any time by filing a properly completed Form 6130, Authorization for Deposit of Retirement Payment.
Required Documents: Please indicate the documentation you are submitting with this form.
Form 6000
Page 4
I acknowledge that electronic payments to the designated account must comply with the provisions of U.S. law, as well as the
requirements of the Office of Foreign Assets Control (OFAC) and National Automated Clearing House Association (NACHA)
regulations. I certify that the entire payment that Kentucky Retirement Systems sends electronically to the financial institution I
have designated, is not subject to being transferred to a foreign bank. I agree to notify Kentucky Retirement Systems in writing
immediately if the payment becomes subject to transfer to a foreign bank in the future.
Attach Voided Check Here:
(Attach Voided Check Here)
Subject to penalty of KRS 523:100: I acknowledge that federal and state law both require a bona fide separation from service with agencies
participating in Kentucky Retirement Systems or entities affiliated with participating agencies in order for Kentucky Retirement Systems to pay a
retirement benefit or to pay a refund of a retirement account.
If I am retiring, I affirm that I have had a separation from service with agencies participating in Kentucky Retirement Systems or entities affiliated
with participating agencies, or that I will have a separation from service with agencies participating in Kentucky Retirement Systems or entities
affiliated with participating agencies prior to my retirement date. I also affirm that I do not have a prearranged agreement to return to a
participating agency or entities affiliated with participating agencies after my separation from service.
If I am taking a refund of my retirement account, I affirm that I have had a separation from service with agencies participating in Kentucky
Retirement Systems or entities affiliated with participating agencies. I also affirm that I do not have a prearranged agreement to return to a
participating agency or entities affiliated with participating agencies after my separation from service.
I understand that the term “separation from service” as used in this affidavit means a complete severance of any kind of employment
relationship (including but not limited to a relationship as an independent contractor or leased employee) with agencies participating in Kentucky
Retirement Systems or entities affiliated with participating agencies.
I understand that the term “prearranged agreement” as used in this affidavit means any contemplation of return to employment with agencies
participating in Kentucky Retirement Systems or entities affiliated with participating agencies.
I understand that the terms “agencies participating in Kentucky Retirement Systems” and “participating agency” as used in this affidavit are to
be construed in a broad manner, and include not only the agency itself, but also any entities affiliated with participating agencies, regardless of
whether such entities are holding themselves out as legally separate entities.
I acknowledge that prior to accepting employment within twelve (12) months of my retirement date with an agency participating in Kentucky
Retirement Systems or entities affiliated with participating agencies, I have a duty to report such employment in writing to Kentucky Retirement
Systems pursuant to 105 KAR 1:390.
I acknowledge and understand that if I fail to comply with federal and state law regarding bona fide separation from service and break in
service, my retirement shall be voided and I shall repay all retirement allowances, dependent child payments, and health plan premiums paid by
the Kentucky Retirement Systems.
OMB No. 1545-0074
Withholding Certificate for
Pension or Annuity Payments
W-4P
Form
Department of the Treasury
Internal Revenue Service
Claim or identification number
(if any) of your pension or
annuity contract
Complete the following applicable lines.
Check here if you do not want any federal income tax withheld from your pension or annuity. (Do not complete lines 2 or 3.)1
2 Total number of allowances and marital status you are claiming for withholding from each periodic pension or
annuity payment. (You may also designate an additional dollar amount on line 3.)
Marital status:
3
Additional amount, if any, you want withheld from each pension or annuity payment. (Note. For periodic payments,
you cannot enter an amount here without entering the number (including zero) of allowances on line 2.)
Type or print your full name.
$
(Enter number of allowances)
Single Married Married, but withhold at higher “Single” rate
FOR TAX YEAR IN WHICH
MEMBER RETIRES
Member ID:
Address:
Section G - Tax Withholding
Member's Signature:
Witness' Signature:
Date:
Date:
I certify the information in this Notification of Retirement is correct and that my employer has been informed of my intent to terminate
employment on the date indicated on this form if applying for early/normal retirement. I understand Kentucky Retirement Systems will send an
estimated retirement allowance. I acknowledge my estimated retirement allowance and benefits are subject to post retirement audit and
adjustment after retirement. I acknowledge that I have full understanding that any person who provides a false statement, report, or
representation is subject to penalty in accordance with KRS 523.100.
Your monthly retirement benefit is subject to federal taxes. You may choose your federal tax withholding preference below. If you
do not complete this section, KRS will automatically withhold federal income tax based on married status with 3 exemptions. You
may refer to the instructions for Form W4-P provided with your retirement application. You may change your tax withholding at
any time by filing a properly completed Form 6017, W-4P, Tax Withholding.
Zip Code:State:City:
Form 6000
Page 5
Date:
Certification of Bona Fide Separation from Service and Notification of Retirement
Spouse's Signature:
NOTE: Signature of Member is required. Signature of either the Spouse or a Witness is also required.
Failure to sign form and have your signature witnessed by either your spouse or another person will result in the form being voided.
THIS PAGE IS INTENTIONALLY BLANK
Section H - Employer Certification of Leave Balances and Final Salary
Employer Code:Employer Name:
Member ID:Member Name:
Termination Date:
Does your agency participate in a sick leave program administered by KRS?
Yes No
If yes above, select the type of sick leave plan: Standard Alternate
Employer's Report of Leave Balances as of:
If no above, please provide an Alternate Average Working Days Per Month:
Does the above member work an average of 21 days per month?
Yes No
Section H must be completed by your current employer and returned to Kentucky Retirement Systems in order to include future
salary, service and sick and compensatory leave balances in your estimated retirement allowance. If you are currently employed
by more than one participating employer, each employer should complete a copy of Section H of this form. If you do not have the
employer complete Section H of this form, Kentucky Retirement Systems will exclude all leave balances from the estimated
retirement allowance. Your estimated retirement allowance and benefits are subject to post retirement audit and
adjustment after retirement.
Standard Sick Leave Program: If participating in the standard sick leave program, please provide the following information.
Note: Contributions should not be withheld from standard sick leave lump sum payouts.
Accumulated Sick Leave (in hours): Hours in a Sick Leave Day:
Alternate Sick Leave Program: If participating in the alternate sick leave program, please provide the following information.
Note: Contributions should be withheld from alternate sick leave lump sum payouts.
Accumulated Sick Leave (in days):
Estimated Compensation to be Paid for Sick Leave:
Hours in a Sick Leave Day:
Section H is continued on the following page. You must complete the Employer Certification at the end of Section H.
School Board Certification (school board employees only): Indicate the number of actual days the member will have
worked through the expected termination date. If the days occur in different school years, please list each school year
separately below.
School Year Number of Actual Days
Actual Days Worked through Expected Termination Date
Form 6000
Page 6
Section H Continued - Employer Certification of Leave Balances and Final Salary
Employer Code:Employer Name:
Member ID:Member Name:
Posting Month Payment Reason Salary
I certify that the leave balances and estimated final salary information provided above is accurate based upon our
agency's records. I state that I have full knowledge of the penalty in KRS 523.100 related to falsification of records and
that the information provided is true and accurate.
Signature of Agency Official:
Title:
Date:
Agency Phone Number:
Employer Certification
You may select from the following payment reasons:
Regular Pay, Regular Pay with Additional Creditable Compensation, Lump Sum Compensatory Pay, Bonus/Severance Payment,
Wages Paid After Term but Earned Prior to Term or Contract Payout - School Board Use Only.
Printed Name of Agency Official:
Employer's Report of Final Salary
Form 6000
Page 7
KRS will provide calculations to the member based upon the information you certify below. Due to the reporting process there
may be a delay from the time you report it to the time it is available for use in the calculation. For this reason we ask that you
verify the actual earned wages for the three months prior to the date you are completing this certification and each month
thereafter through member's anticipated date of termination.
Note to Employer:
Section I - Member's Statement of Disability
If additional space is required to answer the questions, you may use and attach additional paper.
1. List the diagnoses of the injury, illness, or disease for which you are applying for disability:
2. Describe how the diagnoses listed above on this page prevent you from performing your essential job duties:
3. Describe the history of the diagnoses listed above, including the onset or start of your symptoms or complaints:
Please note: A duty related injury does not include the effects of the natural aging process, a communicable disease
unless the risk of contracting the disease is increased by the nature of the employment, or a psychological, psychiatric,
or stress related change unless the direct result of a physical injury.
Yes No
4b. If you are a hazardous employee, are you claiming that you are disabled as a result of an act in the line of duty?
4a. If you are a non-hazardous employee, are you claiming that you are totally and permanently disabled from performing any
occupation for remuneration or profit as a result of a single traumatic event that occurred while you were performing the duties of
your job or a single act of violence committed against you that was related to your job duties?
Yes, this is the direct result of an injury sustained while performing the principal duties of the hazardous position.
No
If you answered yes to 4a or 4b, describe specific date, time, and circumstances of the duty related injury or act in line of duty
below. Please attach a copy of the employer incident report to this form. Failure to attach the employer incident report will delay
your disability application.
Member ID:Member Name:
Form 6000
Page 8
Section I is continued on the following page. You must complete the Certification at the end of Section I.
You will be sent an estimate of disability retirement benefits, subject to post retirement audit and adjustment after retirement,
based upon your last day of paid employment in a regular full-time position assuming your application for disability retirement
benefits is approved. If approved for disability benefits, you will receive benefits effective the first day of the month following your
last day of paid employment.
Month
Day Year
Last Day of Paid Employment:
Last Day of Paid Employment: The last day of paid employment is the last day for which contributions were reported and for
which you were eligible to receive retirement credit. Identify the month, day, and year that is your last day of paid employment, or
if you are still working or on paid leave, identify the month, day, and year that is your anticipated last day of paid employment.
Signature of Member:
Signature of Witness:
Date:
Date:
Certification and Authorization
I certify the information on this Statement of Disability, Section I, is true and correct. I acknowledge that any person who makes a
false statement, report, or representation is subject to penalty pursuant to KRS 523.010 to 523.110.
I authorize the Board of Trustees, its agents, servants, and employees to have full and complete access to any and all medical
records of mine, whether or not related to this injury, illness, or disease, and authorize the Board of Trustees, and its agents,
servants, and employees to discuss such records as it may be necessary at any meeting of the Board in connection with my
application for disability retirement benefits.
I authorize my employer to release, furnish, disclose, or discuss with the Kentucky Retirement Systems all records or other
information regarding my employment, including but not limited to, a description of job duties performed as of the last day of my
employment, a description of the accommodations, assistance, or help that was offered or attempted or reasonably available to
allow me to perform my essential job duties, a report of work injuries or accidents, my personnel file, or other employee records.
Section I Continued - Member's Statement of Disability
Member ID:
Member Name:
Last Day of Paid Employment
Form 6000
Page 9
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Form 6000 - Notification of Retirement: Notification of (Commonwealth of Kentucky)

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Completed 23 September 2020

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