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MEMBER – SCHOOL PLAN EARLY RETIREMENT INDUCEMENT AND TERMINATION CERTIFICATION
Member Certification: School Plan members are required by law to experience a 180-day bona fide separation from service with all
employers participating in the School Plan
1
to be considered “terminated” and eligible to receive a refund or retirement benefit. In
addition, the Internal Revenue Code does not allow individuals who terminate and receive a refund or retirement benefit to prearrange a
return to work.
School Plan members must also disclose receipt of any early retirement inducements. “Early retirement inducements” include, but are
not limited to, any benefit, bonus, insurance payment, salary payment, or wage payment linked to a member’s termination, except for
payments of accrued unused leave converted to cash.
2
Subject to the penalty of prosecution under Neb. Rev. Stat. § 79-949, I certify that:
1. Check one of the following:
I DID NOT accept, have not received, and will not receive, an early retirement inducement.
I DID accept and receive, or will receive, an early retirement inducement. Complete a, b and c.
a. Attach a written description of the early retirement inducement to this form.
b. What is the dollar value of the early retirement inducement? $ _____________________________________.
c. What is the final disbursement date of the early retirement inducement? _____________________________.
2. Check one of the following:
I DO NOT have a verbal or written prearranged agreement to return to service in any capacity with any employer
participating in the School Plan following my termination except intermittent substitute service.
3
I DO have a verbal or written prearranged agreement to return to service in any capacity with any employer
participating in the School Plan except intermittent substitute service. Complete a.
a. Attach a written description of the prearranged agreement to return to service to this form.
3. I understand that I must notify NPERS in writing if I return to service in any capacity with any employer participating in the
School Plan during the 180 days following my termination.
4. I understand that I must notify NPERS in writing if I accept employment under a personal service contract (including as an
independent contractor) with any employer participating in the School Plan during the 180 days following my termination.
5. I understand that I must notify NPERS in writing if I accept employment with a private leasing company, temporary staffing
agency, or any other entity, and my employment requires me to perform work at any employer participating in the School
Plan during the 180 days following my termination.
Member Signature _________________________________________________ Date: ___________________________
Please contact NPERS Call Center at 1-800-245-5712 or 402-471-2053 if you have any questions about completing this form.
1
“Employer participating in the School Plan” means any public school district (except Class V school districts), ESUs, and the Nebraska Department of
Education (NDE) for those employees who are authorized by law to participate in the School Plan while working for NDE.
2
Please refer to Neb. Rev. Stat. §§ 79-902(11) & (44), 79-921, and 79-949, for more detailed information.
3
Intermittent volunteer service or intermittent substitute service may be performed during the 180-day period as long as it is not prearranged.
I understand and acknowledge that knowingly making a false statement or representation to NPERS could result in criminal prosecution
and/or recoupment of distributions made from my NPERS retirement account.
I understand this form should be completed, signed, and received by NPERS before NPERS will distribute any retirement benefits from my
NPERS retirement account. To minimize processing delays I understand this form must be received by NPERS within 20 days of my
termination.
