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Public Employee Retirement Serv

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Public Employee Retirement Serv document sample

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									                                  (SF-239) ERI and Severance for Public School District Personnel

                            AUXILIARY SERVICES MOBILE UNIT REPLACEMENT AND REPAIR FUND
                        REQUES T FOR REIMBURS EMENT OF PAYMENT OF INC ENTIVES FOR EARLY RETIREMENT AND S EVERANC E
                                   FOR S CHOOL DIS TRICT PERS ONNEL ASS IGNED TO PROVIDE AUXILIARY S ERVIC ES


_______________________________________                 ______________________________                          ______________________________
         School District                                         County                                                    IRN #


_ ______________________________________                                       The following information is required for each Auxiliary Services Program person for whom the
         Address                                                               school districts request reimbursement for payment of incentives for early retirement and severance.
                                                                               (For an explanation, please see items 1 through 6 on the instruction page.)
_______________________________________
        City                        Zip


                 (1)                              (2)                             (3)                          (4)                             (5)                                    (6)

             Employee’s                   Non-public                Years of Employment               Total Payment for            % Total Time Worked in               Reimbursement Amount
               Name
                                         School Where                                                Early Retirement and                 Aux Serv                            Requested
                                            Worked                                                         Severance                      Program

                                                                    District        Auxiliary




I hereby certify that the above persons were employed by this school district under the Auxiliary Services Personnel Program to render
services to the non-public schools indicated.

________________________________                        ________________________________                                   _______________________________
Treasurer’s Signature                      Date         Local Superintendent’s Signature                       Date        Superintendent’s Signature                            Date
                                                                                                                           (ESC, City, Ex.Village)



ODE.SFA.FMS.form.SF-239.01/09/2004

								
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