EMPLOYEE EXIT CHECKLIST, UNIFIED SCHOOL DISTRICT 362

Employee Name: ___________________________________

Date: _____________

Address: _____________________________________________________ Initials

(Principal/Administrator/District office staff - Please intial any item that you receive or give to the employee)

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1 Resignation: Employee must present, in writing, a statement of resignation and/or retirement.

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2 Returned USD 362 Keys, gas cards, cell phone, etc: Employee returned the following items to: __________________________________________ _______________________________________________________________________________________________

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3 KPERS Retirement Packet: Complete all applicable forms and return to District Office (F.Y.I. you will be required to submit proof of your date of birth, marriage certificate(s) and/or divorce decree(s) with packet.

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4 KPERS Retirement Information: For your information, you will receive a 'Retirement Options' flyer.

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5 KPERS Leaving Employment Information: For your information, you will receive a 'Leaving Employment and Your Retirment System Benefits' flyer.

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6 KPERS 13 Withdrawal of Contributions Form: Use this form and return to USD 362 if you wish to withdraw your KPERS contributions. Cannot submit until 31 days off the payroll. (you must have contributed for at least 5 years to be vested in KPERS. If non-vested, you will continue to receive interest for 5 years, then you will be required to withdraw your contributions.)

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7 KPERS Group Life Insurance Conversion Forms: Employee must complete and return form to KPERS if converting to a private policy. Due to KPERS 31 days from insurance termination date. (Does employee participate in Optional Group Life? _________ )

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8 Continuing Health Insurance Coverage Notice and COBRA rates: Employee is provided with current law notifications and rates only if currently enrolled in the group health plan. Enroll within 60 days from insurance termination date. (Does employee participate in the health plan? ________ )

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9 Health Insurance Retiree Option: I am retiring and wish to continue on district's group health insurance until age 65. ________Yes _______No (Does employee meet requirements?________)

____ 10 HCRA/DCRA Medical Reimbursement Accounts: Does employee participate in HCRA________ DCRA_______ (Notify them that the remainder of their contribution will be taken from their last paycheck?__________) ____ 11 Benefit Continuation: District office will notify the benefit vendors below of employment termination: _______ American Fidelity _______ Pre-Paid Legal _______ ESSDACK 403B Program Contact the company with any questions regarding options in these voluntary programs. (Give contact info to employee) ____ 12 Direct Deposit: Indicate the stop date for processing direct deposit: _______________. (Discuss employee's final pay.) ____ 13 W-2 Address: Address where W-2 and future correspondence will be mailed: ___________________________________________________________ Full Mailing Address

______________________________ Phone Number

____ 14 Items Returned to Teacher: District will return originals of: teaching license and transcripts to teacher at time of this exit. (District will keep copy for file.)

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Employee Signature Last day worked: ____________________

_____________________

Date

________________

District Office

KPERS final day on payroll, if different: __________________

Clear payroll info in Apta ____________________ Enter End date in KPERS____________ Pull file, mark with end date, file in inactive files.___________

Revised 12/17/2012