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Npers.ne. gov NPERS Nebraska Public Employees Retirement Systems Last First Middle Name Date of Birth Social Security Number - Address Plan Type Check One Retirement Number City Home Phone Work Phone State Zip County Employer State/County Non-Contributing Member Form This form serves as official notification that a member has ceased employment. According to 23-2301 County and 84-1301 State termination of employment occurs on the date on which the state/county determines that the member s employer-employee relationship has dissolved. The employer shall notify NPERS of the date on which termination has occurred. This form is also used if there is any other interruption of a member s retirement contributions such as seasonal employment or a leave of absence. 1221 N Street Suite 325 P. O. Box 94816 Lincoln NE 68509-4816 402-471-2053 or 800-245-5712 Fax 402-471-9493 www. Ceased Employment Termination Date Date of Final Pay Gross Final Pay Emergency Warrant Issued Yes No Reason for Termination Resigned Deceased Disability Retired Transfer from to Dismissed - If dismissed is a grievance or appeal of the termination pending Leave or Intermittent Status Last Pay Date Reason for Change in Status Military Leave Family Medical Seasonal/Intermittent Suspension Other explain Anticipated Date of Return if known This certifies that the above information is correct to the best of my knowledge. Agency/County Signature Date Typed or printed name of Agency Contact Title Telephone Number NPERS2430 Rev* 09/05 PRINT BAR CODE. Ceased Employment Termination Date Date of Final Pay Gross Final Pay Emergency Warrant Issued Yes No Reason for Termination Resigned Deceased Disability Retired Transfer from to Dismissed - If dismissed is a grievance or appeal of the termination pending Leave or Intermittent Status Last Pay Date Reason for Change in Status Military Leave Family Medical Seasonal/Intermittent Suspension Other explain Anticipated Date of Return if known This certifies that the above information is correct to the best of my knowledge. Agency/County Signature Date Typed or printed name of Agency Contact Title Telephone Number NPERS2430 Rev* 09/05 PRINT BAR CODE..

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