Gainful Employment Certification | UHRS

IU 18/20 RETIREMENT PLAN
GAINFUL EMPLOYMENT CERTIFICATION
Period 01/01/2009 through 06/30/2009

REPORTABLE EARNINGS:

In accordance with University policy, IU 18/20 Retirement Plan (Plan) recipients cannot receive Plan benefits while receiving compensation from Indiana University or any other entity funded by the State of Indiana.

	I had NO reportable earnings from Indiana University, any entity funded by the State of Indiana, or any not-for-profit organization that would appear to receive intermediary payments from Indiana University or the State of Indiana. Please click button then complete and submit this* page.*
	I had reportable earnings from Indiana University, an entity funded by the State of Indiana, or a not-for-profit organization that would appear to receive intermediary payments from Indiana University or the State of Indiana. Please click button then complete and submit the next* page.*

Complete the information below if you had NO reportable earnings (* = required field)

EMPLOYEE INFORMATION:

Name: *Last *First M.I.

*Email:

CERTIFICATION AND SIGNATURE:

I certify that to the best of my knowledge the above information is true and correct. I understand that falsification of information will result in the termination of my Plan benefits. I authorize the Social Security Administration to release information to Indiana University, or its agents, in order to verify my reported earnings.

Typing my name in the space provided constitutes an electronic signature and certifies that the information supplied on this form is true and correct.

*Employee signature:

Date:

University Human Resource Services
June 2009