Fillable St Co Non Con (Nebraska)

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St Co Non Con (Nebraska)

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NPERS2430 NPERS2435 NPERS2436
Rev. 08/2018
Page 1 of 1
BAR CODE
Last First Middle
Name
Date of Birth - -
Plan Type
(Check One)
Social Security Number - -
Email Address
(Not Required)
State
County
DCP
Personal
Phone
Employer
State/County/DCP Non-Contributing Member Form
Email this form to NPERS.NonCon@nebraska.gov any time a member ceases working on a permanent or temporary basis. This may
include (but not limited to) resignations, dismissals, death, disability, transfers, retirements, seasonal employment, or leaves of absence.
Indicate if the employee is ceasing employment on a permanent or temporary basis, or if this is a “County to County” or “State Agency
to State Agency” transfer. Submit forms (one form per email please) within 20 days following the last date of employment. Additional
instructions for completing this form are available in your Reporting Agent manual at npers.ne.gov.
Typed or Printed Name of Agency Contact:____________________________________Title:___________________
State Agency/County:________________________________Telephone Number:_____________________________
PERMANENT
TEMPORARY
Termination Date:_______________________
Date of Final Pay:_______________________
Gross Final Pay:$_______________________
Emergency Warrant Issued? Yes No
REASON FOR TERMINATION:
Resigned (2430) Disability (2435)
Deceased (2436) Retired (2430)
Dismissed: If dismissed, is a grievance or appeal of
the termination pending?
Yes No
Other (explain):______________________________
_____________________________________________
_____________________________________________
_____________________________________________
Last Pay Date: _______________________
REASON FOR LEAVE:
Military Leave
Temporary Disability
Family Medical
Seasonal/Intermittent
Suspension
Other (explain):_______________________________
______________________________________________
______________________________________________
______________________________________________
Anticipated Date of Return (if known):
_______________________
If a temporary break turns into a permanent termination, send NPERS an
updated form indicating the date they severed employment.
TRANSFER
(this form is not required for State transfers with NO break in service)
Member is ceasing employment at our (State Agency/County) on:_______________________
Date of Final Pay:_______________________ Gross Final Pay:$_______________________
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St Co Non Con (Nebraska)

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Completed 21 July 2020

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