Employer'S Report Of Death

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KPERS-61 Rev. 1/15
EMPLOYER’S REPORT OF DEATH
„ Contact Us –
toll free: 1-888-275-5737 • phone: 785-296-6166 • fax: 785-296-6638
e-mail: • web site: • mail: 611 S. Kansas Ave., Suite 100, Topeka, KS 66603
„ Part A – Employee Information
1. Employee is covered by:
r KPERS
r Retirement System for Judges
r Board of Regents Retirement
r Elected Official Not in KPERS
2. Social Security Number: ______-____-______
3. Name (First, MI, Last): ______________________________
4. Mailing Address: _________________________________
5. Date of Birth: ______/______/______
City, State, Zip: ___________________________________
6. Membership Date: ______/______/______
7. Last Day Physically at Work: ______/______/______
8. Last Day on Payroll: ______/______/______
9. If there is a break between the last day at work and the last day on the payroll, briefly explain.
______________________________________________________________________________________________________
______________________________________________________________________________________________________
10. Date of Death: ______/______/______
11. If the death was the result of an accident arising out of, and in the course of, the employee’s actual performance of duty with
the employer, briefly describe what the employee was doing and how the accident happened. The incident must have been
independent of all other causes and not as the result of a willfully negligent or intentional act of the employee.
______________________________________________________________________________________________________
______________________________________________________________________________________________________
„ Part B – Compensation and Contribution Information
1. Total Compensation: $_____________________________ earned in the 12-month period of ______/______ (month/year)
through ______/______ (month/year). See instructions on page 2 to determine the 12-month period.
2. Current Annual Rate of Pay: $ _______________________ See instructions on page .
3. If there is more than $2,500 difference between the total compensation and the current annual rate of pay, briefly explain.
______________________________________________________________________________________________________
______________________________________________________________________________________________________
„ Part C – Employer Certification
1. Employer: _______________________________________
2. Employer Number: ________________________________
Designated Agent Signature: ________________________________________________ Month/Day/Year: ______/______/______

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