Form Vwte Employer Verification Of Termination - Arkansas Public Employees Retirement System
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1124 W. Capitol Ave, Ste 400
Little Rock, AR 72201
(800) 682-7377
• •
• •
Employer Verifi cation of Termination
This Form Must Be Completed By The Employer
MEMBER INFORMATION
Name: ____________________________________ Social Security Number: __________________________
EMPLOYER NOTICE
The member listed above has applied for reti rement benefi ts from APERS. Before reti rement benefi ts can begin, members
must terminate their employment with an APERS-parti cipati ng employer/reciprocal employer. In the secti on below, please
verify the member’s last date to earn pay and fi nal earnings informati on. Exclude dates and earnings related to lump sum
payments that the member may receive for unused ti me off or other terminati on-related pay.
TERMINATION AND EARNINGS VERIFICATION
Employer Payroll Representati ve: Verify the member’s last date to earn pay and fi nal earnings informati on. Exclude dates
and earnings related to lump sum payments for unused ti me off or other terminati on-related pay.
1. Member Status.
2. Last date to earn pay:
____________________
Contributory
Non-Contributory
3. Terminati on Date _____________________________
If Diff erent than #2 please explain:_________________
________________________________________________________________________________________________
4. List the member’s compensati on for the fi nal three (3) months through the month of terminati on.
Hours Worked
Service Credit
Monthly Service
80+
4
Month/Year
Monthly Earnings
Credit (1, 2, 3 or 4)
60-79
3
_________________ _________________________
_________________________
40-59
2
_________________ _________________________
_________________________
20-39
1
_________________ _________________________
_________________________
0-19
0
5. List compensati on the member will receive aft er the month of terminati on.
Month/Year
Monthly Earnings
Reason
_______________ _______________________ ______________________________________________________
EMPLOYER CERTIFICATION
I have read the “Employer Noti ce” above regarding members terminati ng their employment before receiving reti rement benefi ts. I
certi fy that based on my knowledge or the informati on provided to me this member has or will terminate employment with this agency
on the date given above and will remain terminated aft er that date except as authorized by reti rement law.
Name: ______________________________________ Signature: __________________________________________
Title: _______________________________________
Employer: __________________________________________
Telephone No: (
)
Fax No: (
)
Date: _______________________________________
Noti ce of Penalty for Falsifying Statements or Records
Any person who knowingly makes any false statements or who falsifi es or permits to be falsifi ed any record in an att empt to defraud
the system as the result of such act shall be guilty of a misdemeanor and shall upon convicti on by a court, be punished by a fi ne of not
less than one hundred dollars ($100) or a maximum of six (6) months in jail or both. Arkansas Code of 1987, as amended, 24-4-102.
08/2011
Form VWTE
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