Form NPERS2020 "Nebraska Judges Retirement System - Verification of Salary and Service" - Nebraska

What Is Form NPERS2020?

This is a legal form that was released by the Nebraska Public Employees Retirement Systems - a government authority operating within Nebraska. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2013;
  • The latest edition provided by the Nebraska Public Employees Retirement Systems;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form NPERS2020 by clicking the link below or browse more documents and templates provided by the Nebraska Public Employees Retirement Systems.

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Download Form NPERS2020 "Nebraska Judges Retirement System - Verification of Salary and Service" - Nebraska

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Last
First
Middle
Plan Type
Name
Date of Birth
-
-
(Check One)
Social Security Number
-
-
Retirement Number
Judges
Address
City
State
Zip
Home Phone
Work Phone
Employer
Nebraska Judges Retirement System – Verification of Salary and Service
PLEASE PROVIDE THE MEMBER’S DATES OF SERVICE IN THE JUDGES RETIREMENT SYSTEM:
Beginning Date:
_____________________________
Month / Day / Year
Ending Date:
_____________________________
Month / Day / Year
.
IF MEMBER WAS EVER ON UNPAID LEAVE(S) OF ABSENCE, PROVIDE INFORMATION BELOW:
Dates of Leave(s)
Reason(s) for Leave(s)
From
To
From
To
From
To
PLEASE PROVIDE THE MEMBER’S LAST FIVE 12-MONTH PERIODS OF COMPENSATION:
12-month period
Salary
From
To
From
To
From
To
From
To
From
To
I CERTIFY THAT THE ABOVE INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE.
Agency Signature
Date
Typed or Printed Name of Agency Contact
Telephone Number
Title
NPERS2020
Rev. 09/2013
Page 1 of 1
BAR CODE
Last
First
Middle
Plan Type
Name
Date of Birth
-
-
(Check One)
Social Security Number
-
-
Retirement Number
Judges
Address
City
State
Zip
Home Phone
Work Phone
Employer
Nebraska Judges Retirement System – Verification of Salary and Service
PLEASE PROVIDE THE MEMBER’S DATES OF SERVICE IN THE JUDGES RETIREMENT SYSTEM:
Beginning Date:
_____________________________
Month / Day / Year
Ending Date:
_____________________________
Month / Day / Year
.
IF MEMBER WAS EVER ON UNPAID LEAVE(S) OF ABSENCE, PROVIDE INFORMATION BELOW:
Dates of Leave(s)
Reason(s) for Leave(s)
From
To
From
To
From
To
PLEASE PROVIDE THE MEMBER’S LAST FIVE 12-MONTH PERIODS OF COMPENSATION:
12-month period
Salary
From
To
From
To
From
To
From
To
From
To
I CERTIFY THAT THE ABOVE INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE.
Agency Signature
Date
Typed or Printed Name of Agency Contact
Telephone Number
Title
NPERS2020
Rev. 09/2013
Page 1 of 1
BAR CODE