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EMPLOYER – SCHOOL PLAN EARLY RETIREMENT INDUCEMENT AND TERMINATION CERTIFICATION
Employer 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.
Employers participating in the School Plan must disclose any early retirement inducements paid to School Plan members. “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. I am the administrator, or authorized designee, of an employer participating in the School Plan which is, or was, the
employer of the above-named member of the School Plan.
2. The member held the position of ___________________________________________________________________.
3. Check one of the following:
The member DID NOT accept, has not received, and will not receive, an early retirement inducement.
The member 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? _____________________________.
4. Check one of the following:
There WAS NO prearranged agreement with the member to have the member return to service in any capacity
with my employer following the member’s termination of employment except intermittent substitute service.
3
There WAS a prearranged agreement with the member to have the member return to service in any capacity
with my employer following the member’s termination of employment except intermittent substitute service.
3
Complete a.
a. Attach a written description of the prearranged agreement to return to service to this form.
I understand and acknowledge that knowingly making a false statement, report, or representation to NPERS could result in
criminal prosecution.
I understand this form must be completed, signed, and received by NPERS within twenty (20) calendar days of the
member’s termination.
Employer Signature ___________________________________ Title: ____________________ Date: _____________
Printed Name: _______________________________________ Employer: ___________________________________
Please contact the NPERS Employer Reporting Section at 402-471-6098 or 402-471-9497 with questions regarding the completion of 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.
