State Of Nevada Resignation Retirement Or Leave Of Absence
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1
2STATE OF NEVADA
9998-500164
CCF-164
5/07
PUBLIC EMPLOYEES RETIREMENT SYSTEM
Agency: CLARK COUNTY SCHOOL DISTRICT - Number: 202
NOTICE OF REMOVAL FROM RETIREMENT REPORT
693 W. Nye Lane
Log #: ______________
Carson City, Nevada 89703-1599
RESIGNATION/RETIREMENT/LEAVE OF ABSENCE
PLEASE PRINT OR TYPE:
Name: __________________________________________________________
SS#: ________ /________ /________
Permanent Mailing Address: __________________________________________________________________________
City/State/Zip: ___________________________________________________
Phone No.: ( ____ ) ________________
Department/School: _____________________________
Location No.: ______
Work Phone No.: _____________
Licensed
School Police
Support Staff
Unified
Position: __________________________________________________________________________________________
(Licensed: subject/assignment; grade; track #)
(Unified, Support Staff, Police: position; months; hours)
RESIGNATION: effective end of day
________ / ________ /________(exact date)
DISMISSAL:
effective end of day
________ / ________ / ________(exact date)
INELIGIBLE:
for membership in PERS
________ / ________ / ________(exact date)
Reason for the above action: ___________________________________________________________________
__________________________________________________________________________________________
TERMINATION: Failure to Complete Probation – effective end of day ________ /_________ / ________ (exact date)
RETIREMENT:
effective end of day ________ /_________ / ________ (exact date)
DISABILITY RETIREMENT:
effective end of day ________ /_________ / ________ (exact date)
DEATH:
________ /_________ / ________ (exact date)
HR USE ONLY- LEAVE:
REQUEST FOR LEAVE OF ABSENCE:
____APPROVED
DATE ________
_______ DENIED
DATE ________
Beginning ________ / ________ / ________
through ________ / ________ / ________
BY: ______________
LEAVE DOCUMENTATION MUST BE ATTACHED. LEAVE CANNOT BE PROCESSED WITHOUT REQUIRED DOCUMENTATION. ALL LEAVES
REQUIRE APPROVAL OF HUMAN RESOURCES ADMINISTRATOR.
REASON FOR REQUEST:
EMPLOYEE NECESSITY
MILITARY
MATERNITY
MEDICAL
PROFESSIONAL
MEDICAL - WORKERS COMPENSATION
OTHER (SPECIFY): __________________________
(Occupational Injury)
(Political, Instructional/Consultant, etc.)
Have you participated in a CCSD ARL program:
Yes
No
_________________________________________________________________________________________________
_______________________________
Employee's Signature (If signature not provided, explanation by Supervising Administrator)
Date Submitted
_________________________________________________________________________________________________
_______________________________
Supervisor/Principal's Signature (As Applicable)
Date Signed
_________________________________________________________________________________________________
_______________________________
Human Resources Administrator/Liaison Officer's Signature
Date Signed
PAY DATA/HR USE ONLY:
Last Day of Paid Compensation: _____ / _____ / _____
Final Paydate: _____ / _____ / _____
Original & 1st Copy – H uman Resources Administrator (Duplicate to PERS)
3rd Copy – Benefits
2nd Copy – Supervisor/Principal
4th Copy – Employee with disposition of HR
031
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