Fillable Vesting CreditDB (Nebraska)

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Vesting CreditDB (Nebraska)

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NPERS2101
Rev. 11/2013
Page 1 of 2
BAR CODE
Last First Middle
Name
Date of Birth - -
Plan Type
(Check One)
Social Security Number - -
School
Patrol
Address City State Zip
Home Phone
Work Phone
Employer
Application For Vesting Credit/Prior Service Credit – School & Patrol
SEE REVERSE SIDE FOR COMPLETE INSTRUCTIONS
School/Patrol Currently
Employed By:
/
/
FT
PT
DATE OF HIRE
LIST ALL NEBRASKA PUBLIC EMPLOYMENT
The following should be completed by you.
Please include all past participation with another Nebraska Governmental Entity
as well as any past participation with your current employer.
BELOW SHOULD REFLECT DATES YOU PARTICIPATED IN ANOTHER NEBRASKA GOVERNMENTAL PENSION PLAN.
PLACE OF EMPLOYMENT
(CHECK ONE)
DATES OF PARTICIPATION
FROM
TO
Full Time Part Time
/
/
/
/
Full Time Part Time
/
/
/
/
Full Time Part Time
/
/
/
/
Full Time Part Time
/
/
/
/
Full Time Part Time
/
/
/
/
IDENTIFY CONTACT PERSON FOR PREVIOUS GOVERNMENT PLAN:
Name:
Dept.:
Address:
Phone:
(
)
-
This form must be completed and received by NPERS
within 180 days of your date of hire.
I hereby certify and warrant that, to the best of my knowledge and belief, the foregoing is true and correct.
Signature
of Member:
Date:
/
/
PRINT
NPERS2101
Rev. 11/2013
Page 2 of 2
BAR CODE
As a new employee you have 180 days to make application for vesting credit.
“Vesting means to qualify for the employer contributions made on your behalf. In the school and state
patrol plans this also means qualifying to receive a monthly retirement benefit.” The application must be
filed with the Public Employees Retirement Systems within 180 days of your date of hire.
All past retirement participation must be in Nebraska Governmental Plans. It is your responsibility to have the
form properly completed and filed.
Print or type all the requested information
TOP SECTION:
School/Patrol Currently Employed By is where you work now.
Date of Hire is the date you commenced working in your new position. If you are with the State Patrol,
this would be your date of graduation from camp. Circle FT/PT to indicate full or part time position.
MIDDLE SECTION:
List your Nebraska Governmental Retirement Plan information and/or past participation with your
current employer here.
Dates are the dates you were in the plan, not when you were employed.
Sign the form and forward it to the Retirement Office immediately. Your Vesting Credit Application will
be considered filed on time if mailed in an envelope properly addressed to the Nebraska Public Employees
Retirement Systems, postage prepaid, and postmarked before midnight of the final filing date. If the final filing
date for such application falls on a Saturday, Sunday, or legal holiday, the next secular or business day shall be
the final filing date. If the application is not mailed, the date the application is received by NPERS shall be the
date used to determine whether the application was timely filed.
NOTE: This is not a buy back. You will be notified by the Public Employees Retirement Board if you qualify
for vesting credit. Vesting credit is not included in the calculation of your benefit.
If you need assistance, call the Retirement Office at 402-471-2053 (Lincoln) or Toll-Free at 1-800-245-5712.
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Vesting CreditDB (Nebraska)

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Completed 18 July 2020

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