CERS Retirement Notice by ls723a4r


									Notice of Intent to Retire – County Employees Retirement System (CERS) Participant
I hereby tender my retirement notice to the Jefferson County Public School District. My retirement will be
effective the first day of _____________________________ 20______.

I fully understand this is my intent notice and not the official retirement form. I am aware, I MUST FILE THE
OFFICIAL RETIREMENT NOTICE at the VanHoose Education Center, Benefits Department,
3332 New burg Road, Louisville, KY. CERS 800-928-4646.

Name: _______________________________________ Last 4 Digits of Social Security No.: ___________

Location/School: _______________________________ Job Title: ________________________________

Home Address: ________________________________________________________________________

City/State/Zip Code: ____________________________________________________________________

Years of full-time service with JCPS: _________________

My signature indicates I understand I must file the official notice of retirement with the Benefits Department,
VanHoose Education Center, 3332 Newburg Road, Louisville, KY 40218.

Signature:___________________________________________ Date: ____________________________

    Mail to:
    Dr. Mary L. Persley
    Director, Classified Human Resources
    Jefferson County Public Schools
    VanHoose Education Center
    3332 Newburg Road
    Louisville, KY 40218

    Fax: 502-485-6044
    Verify Receipt of Fax: 502-485-3226

    Classified Document

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