Everett Public Schools

SICK LEAVE CASH-OUT APPLICATION

I am eligible to cash out my unused sick leave because (mark one):

I have notified Human Resources in writing of my intention to retire; and upon separation from employment

with Everett Public Schools, I will be granted a retirement allowance under the laws governing the

Teachers’ Retirement System or the Public Employees’ Retirement System or the School Employees’

Retirement System.

If the reason you are entitled to these funds is due to your retirement from TRS, PERS or SERS,

please attach a copy of the confirmation letter that you would have received from DRS after your

retirement application was filed.

At the time of separation from employment, I will be at least age 55 and have 15 years of service in the

Teachers Retirement System Plan 2 or 15 years of service in the School Employees’ Retirement System

Plan 2.

At the time of separation from employment, I will be at least age 55 and have 10 years of service in the

Teachers’ Retirement System Plan 3 or 10 years of service in the School Employees’ Retirement System

Plan 3.

I am the executor or personal representative of the estate of a former employee eligible for cash out. In the

event of an employee’s death, a certified copy of the death certificate must be forwarded to Human

Resources.

RETURN COMPLETED FORM AT LEAST 30 DAYS PRIOR TO

YOUR FINAL PAYDATE TO:

Everett Public Schools

Payroll Department

PO Box 2098

Everett WA 98213

The sick leave cash out will be processed

(and your VEBA deposit mailed to the administrator if applicable)

on your final pay date.

If you have any questions, please contact Payroll at (425) 385-4160.

PLEASE TYPE OR PRINT

_________________________________ ________________

______________________________

Employee Name

Social Security No.

Date of Employment Separation or Death

_____________________________________________

_____________________ _____ _______

Mailing Address (for year-end W-2)

City

State

Zip

_____________________________________________ _____________________

Employee or Executor Signature

Today’s Date