Form 6751 - Member And Employer Certification Regarding Reemployment
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1Kentucky 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 6751
Print Form
Revised 01/2010
Member and Employer Certification Regarding Reemployment
IMPORTANT NOTICE: This form will not be accepted unless it is fully completed by both the employer and employee.
Member Information
Please provide your Member ID or Social Security number in the Member ID box below.
Member Name:
Member ID:
Reemploying Agency:
Member Certification
Subject to the penalty of perjury, I certify that:
1. I am receiving or have applied to receive a retirement benefit from one of the retirement plans administered by the
Kentucky Retirement Systems.
2. Check one of the following:
I DID NOT have a prearranged agreement prior to retirement to return to work in any capacity
after retirement with an employer participating in the Kentucky Retirement Systems.
I DID have a prearranged agreement prior to retirement to return to work in some capacity after
retirement with an employer participating in the Kentucky Retirement Systems.
3. If I did have a prearranged agreement prior to retirement to return to work after retirement with an employer
participating in the Kentucky Retirement Systems, I have fully disclosed in writing to Kentucky Retirement Systems
the details of that agreement. I understand that any prearranged agreement could result in the voiding of my retirement
benefit and I could incur significant tax penalties.
4. Are you Medicare eligible?
Yes
No
5. I understand that I have a duty now and in the future to disclose in writing to Kentucky Retirement Systems my
employment in any capacity with an employer participating in the Kentucky Retirement Systems.
6. I understand that I have a duty now and in the future to disclose in writing to Kentucky Retirement Systems if I have
accepted employment under a personal services contract (including as an independent contractor) with an employer
participating in the Kentucky Retirement Systems.
7. I understand that I have a duty now and in the future to disclose in writing to Kentucky Retirement Systems if I have
accepted employment with a private leasing company, temporary staffing agency, or any other company and that
employment means that I will perform work for an employer participating in the Kentucky Retirement Systems.
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:
Employer Certification
To be completed by an employer participating in the Kentucky Retirement Systems.
Subject to the penalty of perjury, I certify that:
My name is
1.
. I am the agency head, appointing authority, or authorized designee of
the employer participating in Kentucky Retirement Systems, which will be the employer of the above-named member.
2. Check one of the following:
I have made personal inquiry and confirmed that my agency DID NOT have a prearranged agreement prior to
retirement with the above-named member to return to work in any capacity following the member’s retirement.
I have made personal inquiry and confirmed that my agency DID have a prearranged agreement prior to
retirement with the above-named member to return to work in some capacity following the member’s retirement.
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:
Title:
Date:
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