Employee Name:                                                             Phone #                                                                               

Address                                                                                                                                                          

I am submitting my formal application for participation in the Voluntary Early Retirement Incentive Plan. This action is taken in accordance with all requirements of the Fairfield Voluntary Early Retirement Plan.

My request for approval of release from my continuing contract(s) and/or letter of employment with the district is made with this application. It is my understanding that my application and request for approval of resignation will be acted upon simultaneously by the Board of Directors.

If my application is accepted, I hereby release and discharge the Fairfield Community School District, its representatives, agents, employees, officers, and directors from any and all liability whatsoever including all claims, demands and causes of action which the employee may have or may ever claim to have by reason of my employment with the District, or the termination thereof and specifically waive any rights or claims which I have or may ever claim to have arising under the Age Discrimination in Employment Act of 1967 (29 U.S.C. 621 et. seq.), excluding claims which may arise after the date of the signing of this Agreement.

I have been advised that I have the right to consult with an attorney prior to signing this Agreement. I acknowledge that I was given at least forty-five days to consider this Agreement. Following the date of signing of the Agreement I shall have seven days to revoke the Agreement. This Agreement will not be effective until this seven day period has expired.

Employee Signature                                                                                                                                  Date                                                                                                              

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

This section is to be completed by the District.

Qualification

1. Birth Date                                                                                                        Age                 (as of June 30)

2. Dates of Service                                                                                              to  ___                 

3. Number of years of service                                                                        

4. Base Salary, year ending 06/30/21 $_____________________

5. Benefit Calculation (Line D x 80%) $____________________

6. First benefit payment of $ _______________________on this date _______________________

7. Second benefit payment of $_______________________ on this date _____________________

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

Date                                                  

Board of Directors Action

Approved                                        Not Approved