Form 210 - Salary Statement For Service 1960 To 1980
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1Form # 210
Revised 4/2016
1400 West Third, Little Rock, AR 72201
Phone (501) 682-1517 or (800) 666-2877
Fax: (501) 682-1812
Website:
SALARY STATEMENT FOR SERVICE
1960 to 1980
County Supervisor, Superintendent of Schools or School Official, should execute this form.
Member Information
Member's Name_____________________________________________ SSN________________________________
Mailing Address___________________________________________________________________________________
City _______________________________ State ______________________________
Zip ____________________
Salaries based on contracts are NOT valid proofs.
“Salary” must be the gross salary actually paid from 7/1 to 6/30.
Total
Days of
Gross
Year
District Name
County
Position
Service
Salary Earned
1960-61 ___________________________ _____________ _____________ __________ $___________
1961-62 ___________________________ _____________ _____________ __________ $___________
1962-63 ___________________________ _____________ _____________ __________ $___________
1963-64 ___________________________ _____________ _____________ __________ $___________
1964-65 ___________________________ _____________ _____________ __________ $___________
1965-66 ___________________________ _____________ _____________ __________ $___________
1966-67 ___________________________ _____________ _____________ __________ $___________
1967-68 ___________________________ _____________ _____________ __________ $___________
1968-69 ___________________________ _____________ _____________ __________ $___________
1969-70 ___________________________ _____________ _____________ __________ $___________
1970-71 ___________________________ _____________ _____________ __________ $___________
1971-72 ___________________________ _____________ _____________ __________ $___________
1972-73 ___________________________ _____________ _____________ __________ $___________
1973-74 ___________________________ _____________ _____________ __________ $___________
1974-75 ___________________________ _____________ _____________ __________ $___________
1975-76 ___________________________ _____________ _____________ __________ $___________
1976-77 ___________________________ _____________ _____________ __________ $___________
1977-78 ___________________________ _____________ _____________ __________ $___________
1978-79 ___________________________ _____________ _____________ __________ $___________
1979-80 ___________________________ _____________ _____________ __________ $___________
I hereby certify that the salary records for the above named member are taken from the official school records.
Signature ______________________________________________ Date____________
Title _______________________________
Telephone Number (____)_______________
Address _____________________________________________________________________
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