Form 6770 - City Appointment Of Retired Police Officer

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Kentucky Retirement Systems
Perimeter Park West
1260 Louisville Rd.
Frankfort KY 40601-6124
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Phone: (502) 696-8800
Fax: (502) 696-8822
kyret.ky.gov
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Form 6770
Print Form
07/2016
City Appointment of Retired Police Officer
IMPORTANT NOTICE: The appointing employer will be invoiced unless this form is fully completed, all supporting
documentation is submitted along with this form, and a response to a properly submitted Form 6751 has been issued by
Kentucky Retirement Systems.
Member Information
Member Name:
Member ID:
Reemploying City:
Employer Code:
Did the member retire as a police officer as defined by KRS 70.291?
Yes
No
Yes
No
Date of the Appointment:
Initial Appointment:
Term of Appointment (cannot exceed one year) :
Employer Certification
Pursuant to Penalty of Perjury, I certify that the following statements are true:
1.
My name is
and I am the Chief of Police for the City of
, which will be employing the retired member identified above;
2. The retired member identified above participated in the Kentucky Law Enforcement Foundation program and I have provided
a certification of participation from the Kentucky Department of Criminal Justice Training, which administers the program;
3. The retired member identified above retired on
from
with no administrative charges pending and I have attached a notarized statement from the agency listed above certifying that
there were no pending administrative charges at the time of the member's retirement;
4. The return to employment for the retired member identified above is consistent with KRS 61.637 and the member has received
a response from Kentucky Retirement Systems approving this return to employment following the submission of Form 6751;
and
5. I acknowledge that if I fail to submit this Form prior to the beginning of the member's term of appointment that Kentucky
Retirement Systems shall administer the member's reemployment pursuant to KRS 61.637 until the first month following
submission of the proper documentation.
I further acknowledge that I have full understanding that any person who provides a false statement, report, or
representation is subject to the penalty of perjury in accordance with KRS 523.010, et seq.
Signature:
Date:
Title:

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