Fillable Name Date of Birth Social Security Number Email (Nebraska)

Fill Online, Printable, Fillable, Blank Name Date of Birth Social Security Number Email (Nebraska) Form

Use Fill to complete blank online NEBRASKA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Name Date of Birth Social Security Number Email (Nebraska)

On average this form takes 6 minutes to complete

The Name Date of Birth Social Security Number Email (Nebraska) form is 1 page long and contains:

  • 0 signatures
  • 13 check-boxes
  • 19 other fields

Country of origin: US
File type: PDF

BROWSE NEBRASKA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
NPERS3000
Rev. 10/2019
Page 1 of 2
BAR CODE
LAST FIRST MIDDLE
Name
Date of Birth
Address City State Zip
Social Security Number Email
Home Phone
or Cell Phone
Most Recent NE
School Employer
The Nebraska School Employees Retirement Plan is a Defined Benefit Plan qualified under § 401(a) of the Internal Revenue Code.
Are you a Nebraska resident? Yes No
If you have a question about your residency status, please contact the Nebraska Department of Revenue.
TERMINATION OF EMPLOYMENT
NPERS WILL CONFIRM THIS DATE WITH YOUR EMPLOYER.
WARNING
Please be informed that if you return to work in a Nebraska Public School that is part of the Nebraska School Retirement Plan
within 180 days from your date of termination, you will be required to repay the total amount of your refund.
SELECT YOUR SETTLEMENT OPTION
1) REFUND MY TOTAL ACCUMULATED EMPLOYEE CONTRIBUTIONS AND INTEREST TO ME.
If you elect to receive a lump sum payment, NPERS is required to withhold 20% Federal Income Tax and if you are a
Nebraska resident, 5% Nebraska State Income Tax.
I wish to have my distribution paid to the following deposit account: [ CHECK ONE ]
Checking Account:
• Attach a completed Direct Deposit Form (NPERS3700).
Savings Account:
• Attach a document issued by your bank which shows account number and routing number
with a completed Direct Deposit Form (NPERS3700).
2) DIRECT ROLLOVER TO: TRADITIONAL IRA ROTH IRA QUALIFIED PLAN
• IMPORTANT: You must attach a completed NPERS3101 Rollover to Financial Institution Form.
• If you selected Roth IRA, you are responsible for paying your own Federal and/or State Income Taxes.
• Any after tax contributions will be sent to you unless you are rolling to a Roth IRA.
• If a Required Minimum Distribution (RMD) is due, you must calculate the RMD amount and request a separate lump sum.
3) COMBINATION REFUND AND DIRECT ROLLOVER.
Lump Sum Portion: Please refund $_________________ OR _______________% of my account.
Where do you wish to deposit the lump sum portion of your refund?
Mark your selection (Checking account or Savings account) in Box 1 and attach Direct Deposit Form (NPERS3700) .
AND
Rollover Portion:
Roll the remaining portion of my account to: TRADITIONAL IRA ROTH IRA QUALIFIED PLAN
Follow the rollover instructions in Box 2.
Refunds (after withholding) of $20,000 or more must be issued via direct deposit into a checking or savings account.
Rollovers of $20,000 or more must be issued electronically via Automated Clearing House (ACH). Please provide us
with the account type, and the account and routing numbers to complete the rollover. If the rollover institution does
not accept ACH transfers, please attach written notification to this form. We cannot accept wire transfers.
You must sign on the reverse side of this form in the presence of a Notary Public.
School Application for Refund/Refund Election
NPERS3000
Rev. 10/2019
Page 2 of 2
BAR CODE
IMPORTANT NOTICE
Termination of employment occurs on the date on which the member experiences a bona fide separation from service of
employment with the member's employer. Your employer is required to report your termination date to NPERS. A member shall
not be deemed to have terminated employment if he/she subsequently provides service to any employer participating in the
retirement system provided for in the School Employees Retirement Act within one hundred eighty (180) calendar days after
ceasing employment unless such service; 1) is voluntary or substitute service provided on an intermittent basis; or 2) is as
provided in subsection (2) of section 79-920 (Department of Education) of the Nebraska Revised Statutes.
A member shall not be deemed to have terminated employment if the Retirement Board determines that a claimed termination
was not a bona fide separation from service with the employer or that a member was compensated for a full contractual period
when the member terminated prior to the end of the contract.
Should you return to employment in a Nebraska Public School after receiving a refund, you must update your beneficiary
designation.
IMPORTANT! A refund erases your years of service credit. In addition, refunds do not include employer matching
contributions. NPERS recommends reviewing the “Terminating Service Before Retirement Age” section of your plan
handbook prior to applying for a refund. If you return to public school employment, contact NPERS regarding repayment
of this service within the statutory deadlines.
WHEN TO EXPECT YOUR REFUND: Members of the School Retirement System who have terminated employment in a
Nebraska Public School are eligible to receive payment of their accumulated account 120 calendar days after date of their
termination of employment or twenty (20) business days after NPERS receives a properly completed and notarized
School Application for Refund / Refund Election (and any applicable rollover documents), whichever is later.
I certify that I have chosen the settlement option on the reverse side of this form. I understand that my selection is irrevocable and if I
return to employment in a Nebraska Public School that is part of NPERS, within 180 days from my date of termination, I will be required to
repay the total amount of my refund.
SIGNATURE OF MEMBER_____________________________________________________________________ Date _________________________________
I hereby certify that the above signer, whose identity I have established to my own satisfaction, freely and voluntarily signed this form
in my presence.
State of __________________________________
County of_________________________________
Subscribed and sworn before me this __________ day of _______________________, ____________.
MONTH YEAR
NOTARY PUBLIC SIGNATURE ________________________________________ My commission expires:___________________
This form must be signed in the presence of a Notary Public.
}
STAMP HERE
PRINT
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Name Date of Birth Social Security Number Email (Nebraska)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 3 December 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document